ABOUT THE PERSON(S) ALLEGEDLY RESPONSIBLE FOR THE ABUSE: Unknown at present: More than one alleged perpetrator? Yes / No (Add details to additional information box on next page) Name: Address: Telephone: DOB: Age: Relationship to Alleged Victim: (List all known) Volunteer? Yes / No Perpetrator’s Employing Agencies: Yes / No / Is the alleged perpetrator an adult at risk? Don’t know If the alleged perpetrator is an adult at risk, do they have capacity to understand their actions? Yes / No / Don’t know Is alleged perpetrator a child? Is alleged perpetrator aware of the referral? Is alleged perpetrator known to Social Services, Yes / No / Yes / No / Health or Police? Don’t know Don’t know ABOUT THE PEOPLE WHO WITNESSED THE INCIDENT(S): Name of Witness Address, inc Post Code Telephone Relationship to Is witness Is witness an Is witness no. victim (if any) a child? adult at risk? aware of referral? WHO HAS RAISED THE CONCERN? Name Address, inc Post Code Telephone Relationship to Occupation / Employer When was the no. victim (if any) disclosure made Does the reporter wish to remain anonymous? Yes / No If yes, explain why: (excludes professionals)
ABOUT THE PERSON(S) ALLEGEDLY RESPONSIBLE FOR THE ABUSE: Unknown at present: More than one alleged perpetrator? Yes / No (Add details to additional information box on next page) Name: Address: Telephone: DOB: Age: Relationship to Alleged Victim: Perpetrator’s Employing Agencies: (List all known) Volunteer? Yes / No Is the alleged perpetrator an adult at risk? Yes / No / Don’t know If the alleged perpetrator is an adult at risk, do they have capacity to understand their actions? Yes / No / Don’t know Is alleged perpetrator a child? Yes / No / Don’t know Is alleged perpetrator aware of the referral? Yes / No / Don’t know Is alleged perpetrator known to Social Services, Health or Police? ABOUT THE PEOPLE WHO WITNESSED THE INCIDENT(S): Name of Witness Address, inc Post Code Telephone no. Relationship to victim (if any) Is witness a child? Is witness an adult at risk? Is witness aware of referral? WHO HAS RAISED THE CONCERN? Name Address, inc Post Code Telephone no. Relationship to victim (if any) Occupation / Employer When was the disclosure made Does the reporter wish to remain anonymous? Yes / No If yes, explain why: (excludes professionals)
-ENG-CWMPAS-Adult-Safeguarding-Referral-Form-MARF-APPROVED-July-2018.docx