Date Signed Please list everyone you have shared / discussed this referral with and when. Name Title Agency Date / Time Confidentiality Notice – This information is shared in accordance with Tees LSCB’s Information Sharing Protocol, if received in please contact the referring organisation. Appendix 1 : Ethnicity SAFER White Black or Black British Asian or Asian British White British African Bangladeshi White Irish Caribbean Indian Gypsy/Roma Any other Black Pakistani background Traveller of Irish heritage Any other Asian Please state: background Any other White background Please state: Mixed/dual background Chinese and other Religion White and Asian Chinese White and Black African Any other ethnic group First Language White and Black Please state: Caribbean Any other mixed Not given background Please state:
Date Signed Please list everyone you have shared / discussed this referral with and when. Name Title Agency Date / Time Confidentiality Notice – This information is shared in accordance with Tees LSCB’s Information Sharing Protocol, if received in please contact the referring organisation. Appendix 1 : Ethnicity SAFER White White British White Irish Gypsy/Roma Traveller of Irish heritage Any other White background Black or Black British African Caribbean Any other Black background Please state: Asian or Asian British Bangladeshi Indian Pakistani Any other Asian background Please state: Mixed/dual background White and Asian White and Black African White and Black Caribbean Any other mixed background Please state: Chinese and other Chinese Any other ethnic group Please state: Not given Religion First Language
Tees_SAFER_Referral_Form_-_24_05_16.docx