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

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Leicester

Tyman House 42 Regent Road Leicester, LE1 6YJ

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Birmingham

54 Hagley Road, Birmingham B16 8PE

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Manchester

2nd Floor, Linley House, Dickinson St, Manchester M1 4LF

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Bradford

Ambler Mills, Valley Road, Bradford, BD1 4RP

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Safeguarding Reporting Form