adult safeguarding report form

Adult safeguarding report form

This form should only be completed by those who do not have access to In-Form whenever an issue or concern has arisen that needs reporting regarding a child or adult. PLEASE ENSURE A COPY OF YOUR COMPLETED REPORT IS SENT TO THE DESIGNATED SAFEGUARDING OFFICER OR DEPUTY DESIGNATED SAFEGUARDING OFFICER (if you can’t find their details you can email it to safeguarding@akt.org.uk)

Date(Required)

Time(Required)

Name of person reporting(Required)

First Last

Position at akt(Required)

Email details of person reporting(Required)

Enter Email Confirm Email

Adult's details

Name of adult(Required)

First Last

Address of adult(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact details of adult(Required)

Adult's date of birth(Required)

Reason (s) for report including names and details where known. What are you worried about?(Required)

Details of alleged perpetrator (s)

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are they also known to akt?(Required)

Action (s) taken by person reporting(Required)

Is the adult aware of your concerns and actions taken?(Required)

Has the adult been asked or consented to a safeguarding refferal?(Required)

If no, why not?

Who else has been informed of these issues?(Required)

Report received by akt DSO/Deputy DSO/Safeguarding lead

Name

First Last

Date