SafeguardingAdults
MULTI-AGENCYALERT
Thisformisforanyagency,organisationorindividualto alertBirminghamCityCouncilAdultsandCommunities Directoratetoallegationsof,orconcernsabout, potentialabuseofanadultwhichshouldbeconsidered undertheSafeguardingAdultProcedures.
Pleasedonotleaveany boxesblank.Ifnecessary,write
‘None’,‘N/K’(notknown)or‘N/A’(notapplicable).
IFCOMPLETING BYHAND,PLEASEUSECAPITAL LETTERS
Section1:Personyouareconcerned about
Lastname:
ACF0030
April2013 (formerlySS1010)
Theofficereceiving thisformmustensure thatthedatetheform isreceivedisstamped inthefirstboxbelow andtheCareFirstIDis enteredinthesecond boxbelow.
Stampthedatereceivedbelow
Firstname:
CareFirstID:
Address:INCLUDING POSTCODE
Telephone1:
Tel2/Mobile:
Preferredlanguage/methodofcommunication:
Interpreterrequired? Doesthepersonyouareconcernedabout
knowyouhavesentthisalert?
Doesthepersonyouareconcernedabout consenttothisalert?
Doyouhaveanyconcernsabouttheperson’s mentalcapacity?
GP/Doctor’sName:
Yes No
Pleaseseebackpage forinstructionsto returnthisformwhen completed.
GP/Doctor’sAddress:INCPOSTCODE
Telephone:
Section2:Nextofkin(orimportantpersoninthelifeofthepersonyou areconcernedabout)
Lastname:
Firstname:
Title:
Relationshiptopersonyou areconcernedabout:
Address:INCLUDINGPOSTCODETelephone1:
Telephone2/Mobile:
Section3:Carer(ifdifferentfrompersoninSection2)
Lastname:
Firstname:
Title:
Relationshiptopersonyou areconcernedabout:
Address:INCLUDINGPOSTCODETelephone1:
Telephone2/Mobile:
Section4:Serviceusergroup (pleasetick onebox only)
AsylumSeeker: ChronicPhysicalHealthCondition: Frailtyand/ortemporaryillness: LearningDisability:
MentalHealth: MentalHealth–Dementia: OtherVulnerableAdult: PhysicalDisability:
SensoryDisability–HearingImpairment: SensoryDisability–VisualImpairment: SensoryDisability–DualSensoryLoss: SubstanceMisuse–Drugs:
SubstanceMisuse–Alcohol: WelfareBenefitsClient:
Section5:Part1–Detailsofallegationsorconcerns
Whataretheallegationsorconcerns?
(Pleaserecordanyinjuriesonthebodymap)
Howandwhendidyou becomeawareoftheconcerns/allegations?
Whendidtheconcerns/allegationstakeplace(datesandtimes)?
Wheredidtheconcerns/allegationstakeplace(address/location)?
Section5:Part1–Detailsofallegationsorconcernscontinued
Pleasegivenamesandcontactdetailsofany witnesses:
Whatactionhaveyou takensofarinrelationtotheconcerns/allegations?
Whereisthepersonyou areconcernedaboutnow(ifnotathome)?
Pleasegiveaddressandpostcode
Isthepersonyou areconcernedaboutsafeatthemoment? Yes:No:
If‘no’,whatactionhaveyou takentoprotectthem?
Havetheemergencyservicesbeencontacted?Yes:No:
If‘yes’,pleasegivedetails:
Section5:Part2–Detailsofperson(s)allegedtohavecommittedthe abuse
Lastname:
Firstname:
Relationshiptopersonyou areconcernedabout:
Address:INCLUDINGPOSTCODE
Wasanyoneelseinvolved?Ifso,pleasegivedetailsifknown:
Lastname:
Firstname:
Relationshiptopersonyou areconcernedabout:
Address:INCLUDINGPOSTCODE
PleaseuseSection8iftherearemorenamestorecord
Section6:Agencyorpersonmaking thealert
NameofAgency/organisation:IFAPPLICABLE
Nameofpersonmakingalert:
Address:INCLUDING POSTCODE
Telephone1:
Telephone2/Mobile:
E-mail:
Fax:
Signature:
Date:
Section7:Otheragenciesinvolved withthepersonyouare concerned about
NameofAgency/organisation:
Nameofpersontocontact:
Address:INCLUDINGPOSTCODETelephone1:
Telephone2/Mobile:
NameofAgency/organisation:
Nameofpersontocontact:
Address:INCLUDINGPOSTCODETelephone1:
Telephone2/Mobile:
NameofAgency/organisation:
Nameofpersontocontact:
Address:INCLUDINGPOSTCODETelephone1:
Telephone2/Mobile:
Section8: Additionalinformation(pleaseusethisspacetorecordany furtherinformation,includingdetailsthatwillnotfitintothe sectionsabove)
ACF0030
April2013 (formerlySS1010)
DataProtectionAct
1998
Wewillkeepthe personalinformation yougiveusonthisform safe.Your information
Section9:Monitoringinformation
Youdonothavetoprovidethisinformation,butit helpsustomonitorhoweffectiveweareinproviding aservicetopeopleinBirmingham.Itisnotusedfor anyotherreason.Pleasecontactusifyouwouldlike moreinformationonequalopportunities monitoring.
EthnicityPLEASETICKONEBOXONLY
isprotectedbylaw.This meansthat:
•weonlyuseitforthe purposewegiveon theform;
•weonlyshareitwith peoplewhoneedto seeit;
•weonlykeepitforas longaswehaveto; and
•youhavetherightto seetheinformation weholdaboutyou.
White UK......
Irish...... WhiteOther...... MixedParentage...... BlackAfrican...... BlackAfricanCaribbean...... Black Other...... Bangladeshi...... Gujarati...... Indian......
If‘Other’,pleasestate:
Kashmiri......
Pakistani...... Sikh...... AsianOther...... Chinese...... Vietnamese...... Yemeni......
Prefernottosay...... Other......
Pleasereturnthe completedformto therelevantAdults
Faith/ReligionPLEASETICKONEBOXONLY
andCommunities office.
Forcontactdetails,visit theBirmingham SafeguardingAdults Boardwebsiteat: report-abuse
Buddhist......
ChurchofScientology...... EasternOrthodox...... Hindu...... Jehovah’sWitness...... Jewish...... Mormon...... Muslim...... OnenessApostolic......
If‘Other’,pleasestate:
Protestant......
Rastafarian...... RomanCatholic...... Sikh...... SeventhDayAdventist......
None...... Prefernottosay...... Other......
Thisformiscopyright©BirminghamCityCouncilAdultsand
CommunitiesDirectorate.Pleasedonotredesigntheform.
FormACF0030•April2013•Page8/8