ACF0030 April 2013 Safeguarding Adults (formerly SS1010) MULTI-AGENCY ALERT This form is for any agency, organisation or individual to alert Birmingham City Council Adults and Communities The office receiving Directorate to allegations of, or concerns about, potential this form must ensure abuse of an adult which should be considered under the that the date the form Safeguarding Adult Procedures. Please do not leave any boxes blank. If necessary, write is received is stamped (not known) or (not applicable). in the first box below ‘None’, ‘N/K’ ‘N/A’ and the CareFirst ID is IF COMPLETING BY HAND, PLEASE USE CAPITAL LETTERS entered in the second Section 1: Person you are concerned about box below. Last name: Stamp the date received below First name: CareFirst ID: Address: INCLUDING Telephone 1: POSTCODE Tel 2 / Mobile: Preferred language / method of communication: Please see back page Yes for instructions to Interpreter required? No return this form when Does the person you are concerned about completed. know you have sent this Does the person you are concerned about consent to this alert? Do you have any concerns the person’s mental capacity? GP/Doctor’s Name: GP/Doctor’s Address: INC Telephone: POSTCODE
Safeguarding Adults MULTI-AGENCY ALERT This form is for any agency, organisation or individual to alert Birmingham City Council Adults and Communities Directorate to allegations of, or concerns about, potential abuse of an adult which should be considered under the Safeguarding Adult Procedures. Please do not leave any boxes blank. If necessary, write ‘None’, ‘N/K’ (not known) or ‘N/A’ (not applicable). IF COMPLETING BY HAND, PLEASE USE CAPITAL LETTERS Section 1: Person you are concerned about Last name: ACF0030 April 2013 (formerly SS1010) The office receiving this form must ensure that the date the form is received is stamped in the first box below and the CareFirst ID is entered in the second box below. Stamp the date received below First name: CareFirst ID: Address: INCLUDING POSTCODE Telephone 1: Tel 2 / Mobile: Preferred language / method of communication: Interpreter required? Does the person you are concerned about know you have sent this Does the person you are concerned about consent to this alert? Do you have any concerns the person’s mental capacity? GP/Doctor’s Name: Yes No Please see back page for instructions to return this form when completed. GP/Doctor’s Address: INC POSTCODE Telephone:
safeguardingadultsmultiagencyalertform.docx