Date that concern or allegations were notified to the Designated Officer: Who has raised this concern or allegation?     Self Family Service Provider Healthcare staff Gardaí  Other (please specify) Type of concern or category of suspected abuse:     Physical Abuse Sexual Abuse Psychological Abuse Financial / Material Abuse     Neglect / Acts of Omission Extreme Self-neglect Discrimination Institutional Setting / Location of concern or suspected abuse:     Own Home Relatives Home Residential Care Day Care Other(please specify) Is this concern/allegation linked to another preliminary screening? If so please give reference   Are there any concerns re: decision making capacity? Yes No Are you aware of any formal assessment of capacity being undertaken?   Yes No Outcome:   Is the Vulnerable person aware that this concern has been raised? Yes No What is known of the vulnerable person’s wishes in relation to the concern / allegation? Are other agencies involved in service provision with this vulnerable person that you are   aware of? Yes No If yes, Details: Details of the first point of contact: Name: Address: Phone: Nature of relationship to vulnerable person (i.e. family member/ advocate etc):
Date that concern or allegations were notified to the Designated Officer: Who has raised this concern or allegation? Self  Family  Service Provider Healthcare staff  Gardaí  Other  (please specify) Type of concern or category of suspected abuse: Physical Abuse  Sexual Abuse  Psychological Abuse  Financial / Material Abuse  Neglect / Acts of Omission  Extreme Self-neglect  Discrimination  Institutional  Setting / Location of concern or suspected abuse: Own Home  Relatives Home  Residential Care  Day Care  Other(please specify) Is this concern/allegation linked to another preliminary screening? If so please give reference Are there any concerns re: decision making capacity? Yes  No  Are you aware of any formal assessment of capacity being undertaken? Yes  No  Outcome: Is the Vulnerable person aware that this concern has been raised? Yes  No  What is known of the vulnerable person’s wishes in relation to the concern / allegation? Are other agencies involved in service provision with this vulnerable person that you are aware of? Yes  No  If yes, Details: Details of the first point of contact: Name: Address: Phone: Nature of relationship to vulnerable person (i.e. family member/ advocate etc):
Protection-and-Safeguarding-of-Vulnerable-Adults-Nov-2017.docx