Service User Details First Name: Surname: NHS No: Address: Date of LAS No. Date Referral Received: Birth: Name and contact details of Lasting Power of Attorney ( if Name and contact details of carer / primary representative ( appropriate): if appropriate): Name: Name: Address: Address: Phone Number: Phone Number: E mail: E mail: Concern to be Where and when it Service Users Referrer’s desired Details of person or Other relevant discussed in the occurred desired outcome outcomes agency who is the Information enquiry cause for concern Does the person require independent support during the enquiry? To be completed by the team and/or the agency leading the enquiry( see guidance notes):
Service User Details First Name: Surname: NHS No: Address: Date of Birth: LAS No. Date Referral Received: Name and contact details of Lasting Power of Attorney ( if appropriate): Name and contact details of carer / primary representative ( if appropriate): Name: Name: Address: Address: Phone Number: Phone Number: E mail: E mail: Concern to be discussed in the enquiry Where and when it occurred Service Users desired outcome Referrer’s desired outcomes Details of person or agency who is the cause for concern Other relevant Information Does the person require independent support during the enquiry? To be completed by the team and/or the agency leading the enquiry( see guidance notes):
Safeguarding-Enquiry-Outcome-Report-Oct-17.docx