Date of Birth/ Gender: Approx. Age: Address: Telephone: Postcode: Email: Is the adult at risk dependent on the person alleged to be Yes No responsible to support them? If in what capacity: ‘Yes’ Does the person alleged to be responsible care for others? Yes No If please give details: ‘Yes’ Ethnic Origin Occupation or Voluntary Position Title (If Known) Organisation person works for (If Known) Is the person alleged to be responsible aware that you are Yes No reporting this? If you think there is a risk of violence (such as domestic abuse), provide details of a safe point and/or mode of contact for the adult. Is there any risk of danger to staff making enquiries Yes No Details: Signature of person completing this form (Accepted as signed when sent electronically) Date: Time: KCC ID Number Date Concern (KCC Office Use) Received (KCC Office Use) Method in which concern has been received (KCC Office Use) Name: Name and Role of Practitioner Receiving the KASAF Role: Further information on submitting this form and the relevant contact information can be found in the KASAF Stage 1 Appendices document .
Date of Birth/ Approx. Age: Gender: Address: Postcode: Telephone: Email: Is the adult at risk dependent on the person alleged to be responsible to support them? Yes No If ‘Yes’ in what capacity: Does the person alleged to be responsible care for others? Yes No If ‘Yes’ please give details: Ethnic Origin Occupation or Voluntary Position Title (If Known) Organisation person works for (If Known) Is the person alleged to be responsible aware that you are reporting this? Yes No If you think there is a risk of violence (such as domestic abuse), provide details of a safe point and/or mode of contact for the adult. Is there any risk of danger to staff making enquiries Yes No Details: Signature of person completing this form (Accepted as signed when sent electronically) Date: Time: Date Concern Received (KCC Office Use) KCC ID Number (KCC Office Use) Method in which concern has been received (KCC Office Use) Name and Role of Practitioner Receiving the KASAF Name: Role: Further information on submitting this form and the relevant contact information can be found in the KASAF Stage 1 Appendices document .