About the people who witnessed the incident WITNESS 1 Name Address: Tel. No. Volunteer/ Other Paid Relative/ Relationship to victim Unpaid Service Other Employee Friend employee User Is witness a child? Yes No Don’t Know Is witness aware of referral? Yes No Don’t know WITNESS 2 Name Address: Tel. No. Volunteer/ Other Paid Relative/ Relationship to victim Unpaid Service Other Employee Friend employee User Is witness a child? Yes No Don’t Know Is witness aware of referral? Yes No Don’t know About the person who first reported the concern (This is the first person to raise the report – it may be the adult at risk, a witness or someone with concerns) Is the person reporting the incident the Adult at Risk? Yes No Is the person reporting the incident a witness to the incident? Yes No Name Address: Tel. No. Volunteer/ Other Paid Relative/ Relationship to victim Unpaid Service Other Employee Friend employee User Date/ Time of Report Does the reporter wish to remain anonymous? Yes No If yes, please state why;
About the people who witnessed the incident WITNESS 1 Name Address: Tel. No. Relationship to victim Paid Employee Volunteer/ Unpaid employee Relative/ Friend Other Service User Other Is witness a child? Yes No Don’t Know Is witness aware of referral? Yes No Don’t know WITNESS 2 Name Address: Tel. No. Relationship to victim Paid Employee Volunteer/ Unpaid employee Relative/ Friend Other Service User Other Is witness a child? Yes No Don’t Know Is witness aware of referral? Yes No Don’t know About the person who first reported the concern (This is the first person to raise the report – it may be the adult at risk, a witness or someone with concerns) Is the person reporting the incident the Adult at Risk? Yes No Is the person reporting the incident a witness to the incident? Yes No Name Address: Tel. No. Relationship to victim Paid Employee Volunteer/ Unpaid employee Relative/ Friend Other Service User Other Date/ Time of Report Does the reporter wish to remain anonymous? Yes No If yes, please state why;
adult-safeguarding-report-enquiry-form.docx