Reporting Form - Safeguarding Adults - Menopause and Cancer with Dani Binnington

Download Reporting Form – Safeguarding Adults

Menopause and Cancer Community Interest Company

Safeguarding Adults at Risk

Reporting Form

Use this form to record a concern that you have about an adult at risk at Menopause and Cancer Community Interest Company.

Remember, if it is an emergency and the person is in immediate danger, phone the police on 999.

Otherwise, once completed, please pass this form to Dani Binnington, designated Safeguarding Officer. See the Menopause and Cancer Community Interest Company Safeguarding Policy for details.

IMPORTANT: Please write clearly and only write facts of what you heard or saw, even if the language used was unpleasant. If you do need to clarify anything, please state clearly that

Date of incident
Time of incident
Location of incident
Section A: DETAILS OF ADULT AT RISK
Name
Date of Birth
Disability If yes, please detail:	YES NO
Do they have care and support needs?If yes, please detail:	YES NO
Preferred language
Address
Telephone number
Do they have a carer Y/NIf yes, the carer’s name?
Address of carer, if different from above
Section B: HOW YOU BECAME AWARE OF THE ALLEGED ABUSE OR NEGLECT(tick as appropriate)
I witnessed an incident directly
I have concerns based on potential indicators of abuse or neglect
The adult told me directly about abuse or neglect they are experiencing
Someone else told me about potential abuse or neglect of an adult.	Their name is:Their relationship to the adult is:Their contact details are:
Section C: FULL DETAILS OF THE ALLEGED ABUSE OR NEGLECT
DETAILS Please give full details of the incident/concern/alleagtion of abuse or neglect
What exactly did you see/ hear/ witness? IMPORTANT: Please write clearly and only write facts of what you heard or saw. Use exact words, even if the language you heard was unpleasant. If you do need to clarify anything, please state clearly that is it your opinion or assumption.
Where (exact location/venue)
When the incident is alleged to have taken place (date and time)
YOUR OBSERVATIONSPlease include your observations here:
A description/ location of any visible injuries
A description of the adult’s behaviour, their physical or emotional state
ADULT AT RISK REPORTING THE ABUSE OR NEGLECTOnly complete this section if the adult at risk reported the incident to you. Record exactly what the adult has said happened using their exact words, even if this is unpleasant language, and anything you said to the adult. Remember you should not investigate, but simply record here.

SECTION D: ALLEGED ABUSERDo you have any details about the alleged abuser Y / N
Name:
Address:
Tel number:
Their relationship (if any) to the adult at risk:
Is the alleged abuser a member of staff/ volunteer/trustee or working with the charity in any way?	YES If so,Their role …………………… IMMEDIATELY REPORT THIS TO THE DESIGNATED SAFEGUARDING OFFICER
SECTION E: REPORTING THE INCIDENT INTERNALLY
Are carer’s / family members aware of the concerns / allegations?	YES NO
If yes, how did they become aware?
Is the alleged abuser aware of the concerns / allegations?	YES NO
If yes, how did they become aware?
Who did you report this to in the organisation
Date and time reported
Has the adult consented to you reporting this to the Designated Safeguarding Officer	YES NO
Signed by person making this report
PRINT YOUR NAME
Your Role in organisation

THANK YOU FOR COMPLETING THIS FORM.

PLEASE NOW PASS THIS FORM TO THE DESIGNATED SAFEGUARDING OFFICER OR SAFEGUARDING TRUSTEE.

Please remember your responsibility for data protection. Do not leave this information in an insecure location or discuss with anyone else.

THE REST OF THIS FORM SHOULD BE COMPLETED BY DESIGNATED SAFEGUARDING OFFICER / SAFEGUARDING TRUSTEE

SECTION F: REPORTING EXTERNALLY
Have you reported this to the Adult Social Care Team?	YES NO
Who did you speak to
Date and time reported
Case referene number (if any)
Advice given by Social Care team
Have the police been informed?	YES NO
If yes, who did you speak to?
Any case reference number?
What action are the police taking, if any?
Detail any other partner organisations you have shared this information with, and reasons? Please include name and contact details.
SECTION G: ADULT AT RISK’S CONSENT AND WISHES
Is the adult at risk aware that you are reporting the concern to Social Care, Police or other agencies?	YES NO
Have they consented to this?
Please complete here any further information in respect of their wishes
Any further action you will take

THANK YOU FOR COMPLETING THIS FORM.