SA1 - Safeguarding Adults Alert Form - Confidential
Form Start DateFamily name / Given name
Date of birth (dd/mm/yyyy)
NHS Number / Social care ID
Gender / FemaleMale / Preferred language
Religion / ChristianMuslimHinduSikhJewishBuddhistAny other religionNoneNot stated / Ethnicity / White BritishWhite IrishAny other white backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other mixedIndianPakistaniBangladeshiAny other AsianBlack CaribbeanBlack AfricanAny other black backgroundChineseGypsy/RomaTraveller of Irish originAny other groupRefusedInformation not yet obtainedNot stated
Marital Status / SingleMarriedCivil partnerDivorcedCivil partnership dissolvedWidowedSurviving civil partnerSeparatedNot disclosedNot known / Does the person need an interpreter
Current address / Did this incidence of abuse occur at the service users main address
Type of Accommodation / Own homeLiving with family/friends (short term)Living with family/friends (long term)Hospital/NHS facility (short term)Intermediate care facilityHospital/NHS facility (long term)HospiceResidential home (short term)Residential home (long term)Nursing home (short term)Nursing home (long term)Adult placementSupported/sheltered housingTemporary accommodationPrison/other criminal justice facilityNo fixed abode/night shelter/refugeOther
Client Group / Asylum SeekerCarersDementiaFrailty/and or temporary illnessLearning DisabilityMental HealthMental Health Support Needs and alcoholMental Health Support Needs and drugsMental Health Support Needs and substance misuseNo Social Care Needs IdentifiedOther Vulnerable PersonPhysical DisabilitySensory Disability Hearing ImpairedSensory Disability - visually impairedSensory Disability - dual sensory loss (deaf blindSubstance misuse - alcoholSubstance misuse - drugsSubstance misuse - drugs and alcoholSubstance misuse - alcohol with mental health needSubstance misuse - drugs with mental health needsSubstance misuse - drugs and alcohol with mental h
GP and Next of Kin Details
Next of kin / GP
Relationship / Practice
Tel no / Tel no
Address
Email address / Email address
What type of care/support plan does the service user have / Commissioned Care PlanCommissioned Care Pan - other LADirect PaymentHealth FundedNo Care PlanSelf Directed SupportSelf Funded
Who provides the care plan
Is the alert against the provider / yesno
Details of alleged incident
Date of Alleged Incident
Time of Alleged Incident
Location of Alleged Incident / acute hospitalalleged perpetrator's homecare home - permanentcare home - temporarycare home with nursing - permanentcare home with nursing - temporarycommunity hospitalday centre/serviceeducation/training/workplaceestablishmentmental health inpatient settingnot knownotherother health settingown homepublic placesupported accommodation
If alleged incident did not occur at client's Main address, give details of where this happened e.g. name of home
Day Centre/ServiceGeneral HospitalIndependant HealthCareNot KnownNursing / Care homeOtherOwn HomePerpetrator's HomePublic PlaceRelative's HomeResidential HomeRespite HomeSheletered AccomodationSpecialist/Community Hospitalsupported Housing
Brief Description of Alleged Incident
Type of Abuse / DiscriminatoryFinancialInstitutionalNeglect/Act of OmissionNot KnownPhysicalPsychologicalSexualVerbal
Have the Police been informed? / yesno
Police Reference Number
Name and Contact Details of All Witnesses
Details of Alleged Perpetrator
Details of Alleged Perpetrator
If Alleged Perpetrator is a Vulnerable Adult, please enter their Client ID Number
Alleged Perpetrator’s relationship to the service user / daughter daughter - also carerday care staffdomiciliary care staffhealth care workerneighbour/friendnot knownotherother family memberother family member - also carerother professionalother vulnerable adultpartnerpartner - also carerresidential care staffself directed care staffsocial worker / care managersonson - also carerspousespouse - also carerstrangervolunteer / befriender
Does the alleged perpetrator live with the victim
Any other information relating to the alleged perpetrator
Is the Alleged Perpetrator aware of the Referral/Alert? / yesno
Details of Alleged 2ndPerpetrator(if applicable)
If the 2nd alleged Perpetrator is a Vulnerable Adult, please enter their Client ID Number
2nd Alleged Perpetrator’s relationship to the service user / daughter daughter - also carerday care staffdomiciliary care staffhealth care workerneighbour/friendnot knownotherother family memberother family member - also carerother professionalother vulnerable adultpartnerpartner - also carerresidential care staffself directed care staffsocial worker / care managersonson - also carerspousespouse - also carerstrangervolunteer / befriender
Does the 2nd alleged perpetrator live with the victim
Any other information relating to the alleged perpetrator
Is the 2ndAlleged Perpetrator aware of the Referral/Alert? / yesno
Details of Person notifying Alleged Abuse
Details of Person who notified the abuse
Other contact details for person notifying abuse
Source of Referral: / care quality commissionday care staffdomiciliary care staffeducation/training/workplace establishmentfamily memberhousingneighbourotherother service userother social care staffpoliceprimary/community health staffprobation / other criminal justice systemresidential care staffsecondary health staffself self directed care staffsocial worker / care manager
Organisation:
Actions:
Has the Vulnerable Adult been deemed to have mental capacity in relation to these safeguarding issues? / yesnoNot Known
Does the Vulnerable Adult know that this alert has been made?
Does the Vulnerable Adult give consent for an investigation to proceed?
Brief Description of Action taken so far:
Assessment of presenting risk and response
Is the Alert Form ready to be authorised as agreed with your Manager?
Is the Safeguarding process completed?
Assessment Completion and Authorisation
Completed by / CareFirst NumberRole/profession / Care / Support Team
Authorised by / CareFirst Number
Role/profession / Care / Support Team
Assessor’s Signature
Supervisor’s Signature
Newham . Background & Contact Assessment V.1.7 June 2009 Page 1