SET SAF 1 SAFEGUARDING ADULT CONCERN FORM – Date Form Completed: Service User reference/NHS No: (Swift/PRN/NHS) (if known) 1.Tell us if the concern is for a person or an Organisation: (please complete as much of this as is known if not known put N/K) – Name of person who you are concerned about: Organisation: Gender: Home Address: Telephone Number: Age: DOB: Ethnic Origin and or Nationality: Does the person have any Communication Needs: Are they aware of this referral Yes No Have they agreed to this referral: Yes No If not, why not: Is the adult in receipt of any social or health Yes No Not Known care services: If yes, please give details: 2a. Current Situation and Details of the Incident/Concern(s) being raised – Does the person continue to be at risk of harm? Yes No Are there other people who may be at risk of Yes No harm? If the answer to either of the above is yes, please describe the risk that remains and the names of any others potentially at risk: (please only to identified risk that relates directly to the concern) 2b. Details of the concern(s) being raised Time of incident: Date: Location of Incident: Concern: What would the adult like as the outcome of the enquiry: Brief factual details of the incident:
SET SAF 1 – SAFEGUARDING ADULT CONCERN FORM Service User reference/NHS No: (Swift/PRN/NHS) (if known) Date Form Completed: 1.Tell us if the concern is for a person or an Organisation: (please complete as much of this as is known – if not known put N/K) Name of person who you are concerned about: Organisation: Gender: Home Address: Telephone Number: Age: DOB: Ethnic Origin and or Nationality: Does the person have any Communication Needs: Are they aware of this referral Yes No Have they agreed to this referral: Yes No If not, why not: Is the adult in receipt of any social or health care services: Yes No Not Known If yes, please give details: 2a. – Current Situation and Details of the Incident/Concern(s) being raised Does the person continue to be at risk of harm? Yes No Are there other people who may be at risk of harm? Yes No If the answer to either of the above is yes, please describe the risk that remains and the names of any others potentially at risk: (please only to identified risk that relates directly to the concern) 2b. Details of the concern(s) being raised Time of incident: Date: Location of Incident: Concern: What would the adult like as the outcome of the enquiry: Brief factual details of the incident:
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