If the person is at immediate risk call emergency services first on 999.

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1 Children, Adults and Health Safeguarding Alerter Form About this form Please ensure that this form is completed as fully as possible and returned the same day. Gaps in information may put people at further risk but it is very important we act promptly therefore, if you are conducting an internal investigation please do not delay the return of this form. Please complete one form for each victim. If you are unsure about completing any part of this form please contact the CSO desk on For incidents relating to the professional provision of care, if the organisation involved is registered with CQC, please also inform them of this incident. If the person is at immediate risk call emergency services first on 999. If you think a crime has been committed, the police should be contacted first on 101 before completing this form. Please record the crime reference number here. 1. Persons Details Full name Address Date of Birth AIS no NHS If the person is at immediate risk, have emergency services been called? N/A Date (and time if known) incident occurred Date of reporting incident. (If not the same date, please state delay reason) Date form completed Alerter SA1 (Apr 15) Page 1 of 11 «ACSANCS_CONTACTSUBJECTIDENTIFIER»

2 What actions have been taken to make the person safe? Please keep all information confidential and ensure evidence is not tampered with. You will receive advice from us or the Police about what to do next. Mental Capacity: In the opinion of the referrer does the person appear to have mental capacity to make decisions in relation to the alleged abuse? Is the person aware of the referral? Ethnicity Recorded ethnicity If ethnicity is not recorded please tick the appropriate category below White White British Asian / Indian White Irish Asian Pakistani Traveller of Irish Heritage British Bangladeshi Gypsy or Chinese Mixed Unknown Roma Any Other White Background White and Black Caribbean White and Black African White and Asian Any Other Mixed / Multiple Ethnic Background t stated / Refused Undeclared / t Known Black / African / Caribbean / Black British Other ethnic Groups Any Other Asian Background Caribbean African Any Other Black / African Background Arab Any Other Ethnic Group Alerter SA1 (Apr 15) Page 2 of 11

3 Support Reason Recorded Support Reason If the support reason is not shown, please tick the appropriate primary and secondary support reason (where applicable) below: Primary Support Reason Physical Support: Access & Mobility Only Physical Support: Personal Care Sensory Support: Visual Impairment Sensory Support: Hearing Impairment Sensory Support: Dual Impairment Memory and Cognition Support Learning Disability Support Mental Health Support Social Support: Carer Social Support: Substance Misuse Social Support: Asylum Seeker Social Support: Social Isolation / Other Support Reason is Unknown Support Reason Learning Disability (Further Information) If the victim has a learning disability please clarify what form this takes by putting a tick against the relevant category below Autism (excluding Asperger s Syndrome / High Functioning Autism) Asperger s Syndrome/ High Functioning Autism The learning disability takes another form. Please describe the learning disability: GP details: GP Name Surgery Address Tel. Alerter SA1 (Apr 15) Page 3 of 11

4 Who arranges services for the person? Put a tick against as many answers as are relevant South Gloucs. Council - NHS e.g. CHC Children, Adults and Health (incl. Supporting People) Other Local Authority, please t Known / services specify Person arranges their own services using a Direct Payment (from a local authority to fund services) Self funding Other (Please Detail) Please give details of any professional worker involved with the person Name Position / role Organisation (and address if known) Telephone. Alerter SA1 (Apr 15) Page 4 of 11

5 2. Details of the allegation Give a full and detailed account of the abuse and how it was discovered. Please write on a separate sheet if necessary, providing copies of incident reports, body maps and risk assessments Type of abuse suspected (victim abuse categories): Put a tick against as many types as are relevant Financial / Material Physical Sexual Abuse Sexual Exploitation (a form of sexual abuse) Neglect / Acts of omission Organisational Domestic Abuse Modern Slavery Discriminatory Self Neglect Psychological / Emotional Alerter SA1 (Apr 15) Page 5 of 11

6 Domestic Abuse: This is abuse by the victim s current or ex-partner, family member or someone they live with. Such abuse often shows a pattern of control and coercion. If domestic abuse is suspected: Have you completed a DASH risk assessment & implemented the necessary safety actions, including MARAC referral if required (please tick one box below)? Do you feel that this safeguarding incident constitutes any of the following? Put a tick against as many types as are relevant Hate Crime and Prejudice Motivated Incidents: Persecution which is perceived by the victim to be based on their race, religion, sexual orientation, disability or transgender identity, even if they are wrongly associated with a group by the perpetrator. Mate Crime: Exploitation or persecution of an individual by a person claiming to be their friend. Anti-Social Behaviour: Any aggressive, intimidating or destructive activity that damages or destroys another person s quality of life. If yes, have you referred the case to the Anti-Social Behaviour Team (please tick one box below)? Was there a witness/whistleblower (please detail)? Witness 1 Name Organisation First line of address Second line of address Tel. Alerter SA1 (Apr 15) Page 6 of 11

7 Witness 2 Name Organisation First line of address Second line of address Tel. Which of these terms best describes the location of the alleged abuse: Please tick the most appropriate category below Own Home Other Person s Home Alleged Perpetrator s Home Care Home Mental Health Inpatient Setting Other Health Setting (incl. hospice) Supported Accommodation Service in the Community e.g. social club, support group or day care service [not based in a care home] Care Home with Nursing Acute Hospital Community Hospital Public Place Education / Training / Workplace Other (Please detail below) Community Setting e.g. a public house, café etc t Known At what address did the alleged abuse take place? Name of Location (e.g. Care home name, public facility name) First line of address Second line of address Third line of address Alerter SA1 (Apr 15) Page 7 of 11

8 If not permanently resident in a care home, who does the subject of this report normally live with (e.g. partner, family, other relative, carer, friends etc) Names Approx. Age Address (incl. ) House. Add. Line 1 Add. Line 2 Relationship of the alleged Perpetrator to the subject of this report Please tick the most appropriate category below Social Care Support or Service paid, contracted or commissioned Public Sector Domiciliary Care Public Sector Residential Care (incl. nursing care) Public Sector Day Care (incl. Social clubs and Support Groups) Private Sector Domiciliary Care Private Sector Residential Care (incl. nursing care) Other - Known to Individual Partner Relative/Family Carer (not partner) Individual Other vulnerable adult Individual t vulnerable adult Social Care Staff (Care Management & Assessment) Primary Health Care Other Unknown / Stranger Individual Other vulnerable adult Individual t vulnerable adult Social Care Staff (Care Management & Assessment) Primary Health Care Secondary Health Care Private Sector Day Care (incl. Social clubs and Support Groups) Voluntary - Domiciliary Care Voluntary Residential Care (incl. nursing care and hospice) Voluntary Day Care (incl. Social clubs, charities & support Groups) Secondary Health Care Community Health Care Other Public Sector Other Private Sector Other Voluntary Community Health Care Other Public Sector Other Private Sector Other Voluntary Alerter SA1 (Apr 15) Page 8 of 11

9 Alleged perpetrator details Perpetrator s Name Perpetrator s date of birth / approx. age Does the alleged Please tick one box below perpetrator live at the same address as the victim? Did the reported issue Please tick one box below arise from the provision of professional care / support services? Is the alleged perpetrator Please tick one box below the main family carer? Name of perpetrator s employer / their trading name (if self employed) Perpetrator s address or employment address (if different to the victim) House. Add. Line 1 Add. Line 2 Is the alleged perpetrator a person who is, or may be, in need of community care? Don t know Period of abuse - was the alleged abuse... A one-off incident On going Targeted individual Could other people be at risk?. Please give details of who they are and what has been done to make them safe. Alerter SA1 (Apr 15) Page 9 of 11

10 Are there any children/young people at risk?. Has the South Gloucs. Council Children & Young People Team been informed (their number is )? Please give details below of any communication / discussion. 3. Details of the person raising the alert Full name Role &/or agency (as applicable) Address Telephone. Fax.. Date Alerter Sent to SGC House. Add. Line 1 Add. Line 2 4. Alternative contact details Full name Role &/or agency (as applicable) Address Telephone. Fax.. House. Add. Line 1 Add. Line 2 te: When completing this form always ring the Customer Services Desk before faxing it into South Gloucestershire Council. Do not send this form directly to the Public Protection Unit Tel: Fax: Alerter SA1 (Apr 15) Page 10 of 11

11 5. For South Gloucestershire Council Staff Only Always consult with the Screening Officer to confirm whether to fax to the Public Protection Unit (PPU) with the Alert. On receipt of a completed Alerter Form (SA1): 1. Check the details for content and accuracy. 2. Ring the Public Protection Unit to inform them of the alert as appropriate Contact details for PPU Tel: or Alerter SA1 (Apr 15) Page 11 of 11

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