Safeguarding Reporting Form

Your Details (the person completing the form)

Full Name*

Email:*

Designation*

Campus*

Contact number:*

Details of the person affected

Full Name*

Date of Birth

Designation (for staff) or Cohort (for students)

Campus*

Email:

Contact number:

Details of the Incident: (please describe in detail only using the facts) *

Others present or potential witnesses:

Full Name

Course/Cohort/Designation

Email:

Contact number:

Involvement of the adult(s) at risk:

The following section is crucial to determining the next steps in the safeguarding adult’s enquiry and every attempt should be made to complete it as fully as possible:

Has the adult(s) at risk given consent for this referral? *

If no, please confirm why you have not sought consent or are overriding consent (please select one or more):

Other, please provide details below:

Do you think the adult at risk has the mental capacity in relation to making decisions about their safety?*

If No, has a mental capacity assessment been undertaken?

Do you think the adult at risk would have substantial difficulty in participating in the safeguarding adult's process?*

If yes, is there a suitable person who could represent them? (e.g. family member, friend, advocate)*

Please provide the name & contact details of this suitable person:*

Has the adult at risk’s family been informed of the concerns (where the adult has consented to this)?*

If you think the adult at risk may need support to participate in the safeguarding adult's process, please provide details of what support may be:*

Additional Relevant Information:*

I have completed this form and provided information that is factual and does not contain my own views or opinions on the matter.

Signature:*

Date:*

London

Westlink House, 981 Great West Road, Brentford TW8 9DN

Get Direction

Leicester

Tyman House 42 Regent Road Leicester, LE1 6YJ

Get Direction

Birmingham

54 Hagley Road, Birmingham B16 8PE

Get Direction How to get here?

Manchester

1st Floor, Boulton House, Chorlton Street, Manchester M1 3HY

Get Direction

Bradford

Ambler Mills, Valley Road, Bradford, BD1 4RP

Get Direction

Search Courses