Ethnic origin: Black Caribbean Black African Other Black Mixed WH/BL Caribbean Mixed WH/BL African Pakistani Bangladeshi Indian Mixed White/Asian Other Asian Chinese WH/Chinese White British White Irish Other White Other, please specify: Religion: Christian Greek Orthodox Roman Catholic Hindu Jewish Buddhist Muslim Sikh No religion Other, please specify: ALLEGED/SUSPECTED/ WITNESSED OR REPORTED Does the adult in concern know this alert has been made: Yes No Has the adult in concern given consent to proceed to an investigation? Yes No Description of the alleged/suspected or witnessed abuse: What was seen/said/heard, by whom, who else was present etc. Record factually what the person said and make a note of the time, date to who and where they made the admission. If comments are recorded and retained in this way there is a greater likelihood that the evidence will be allowed as evidence in court. Continue on a separate sheet if necessary. Date & time of alleged, suspected or witnessed abuse: Date & time alert reported: Impact on the adult concerned, including any injuries: Continue on a separate sheet if necessary. Abuse setting: Alleged victim’s home Alleged perpetrators home Family Home family members home Residential Home – Permanent Residential Home – Temporary Nursing Home – Permanent Nursing Home – Temporary Adult Placement Home Mental Health Inpatient Setting Hospital Community Hospital Other Health Setting Day Centre Public Place/Outside Home Supported Living (inc sheltered, extra care housing) Education/Training/Workplace Establishment Not Known Other (Please Specify): Type of abuse: Neglect/Act of Omission Financial or Material Abuse Organisational Abuse Hate Modern Slavery Psychological/Emotional Discriminatory Abuse Sexual Abuse Domestic Violence Physical Abuse Self Neglect
Source of referral: Residential/Nursing Care Staff Social Worker Or Care Manager Primary Or Community Health Staff Self Referral Other Service User Domiciliary Care Staff Housing Services London Ambulance Service GP Voluntary Agencies Self Directed Care Staff Secondary Health Staff Day Care Staff Mental Health Staff Family Member Other Social Care Staff Friend/Neighbour Police Education/Training/Workplace Establishment Care Quality Commission Other (Please Specify): Has alleged abuse been referred to the police? Yes No CAD or Police/crime reference number? Does the adult at risk have any special needs in relation to communication, physical access or mobility, medication or personal care: Does the adult have/need an advocate? Yes No PERSON ALLEGED TO HAVE CAUSED HARM DETAILS (Do Not put details if employed by the Local Authority) Do not speak with the perpetrator first without seeking advice from police or the Safeguarding Adults Manager. Full name: Include any nicknames Address : Indicate if known at more than one address: Postcode: (If known): DOB: Age Gender: Male: Female: Is person alleged to have caused harm Partner Domiciliary Care Staff Friend/Neighbour Self Directed Care Staff Statutory Agency Residential Care Staff Another Service User Health Care Worker Day Care Staff Stranger Institutional Other Family Member Social Worker Care Manager Other Social Care Staff Volunteer/Befriender Other Not Known Is the person alleged to have caused harm the main carer? Yes No Still living with adult at risk? Yes No Was person alleged to have caused harm living with the adult at risk at the time of abuse? Yes No Please provide details of relationship to adult at risk. Details of immediate action taken to safeguard the adult at risk (if any).