Internal Safeguarding Form Your Full Name * First Name Last Name Your Contact Details Name of Person at Risk (if Known) First Name Last Name Contact Number of the Person at Risk (if Known) Address of Person at Risk (if Known) What are you reporting? * Reporting an Incident Raising a Concern Reporting an Incident Where did the alleged incident take place? At the person at risk's address Another location If it occurred at another location, please enter details below What date did the alleged incident occur? MM DD YYYY What time did the alleged incident occur? Hour Minute Second AM PM Was an emergency call to the police made? Yes No If the Police were called, please let us know the crime reference or log number If the incident was witnessed by another member of staff, please enter their name below and explain why you are reporting this on their behalf Please provide a summary of the incident below Raising a Concern What is the nature of this concern? Physical abuse (including hitting, slapping, kicking, misuse of medication, restraint and force-feeding) Domestic Violence (including threats of harm or abandonment, isolation, humiliation, blaming, controlling, intimidation, harassment, verbal abuse, threats or bribes) Financial/Material (including theft, fraud or using a person's money, possessions or property without consent) Psychological/Emotional (including threats of harm or abandonment, isolation, humiliation, blaming, controlling, intimidation, harassment, verbal abuse, threats or bribes) Sexual (including sexual assault, rape or sexual acts to which the vulnerable adult has not consented, could not consent, or was pressurised into consenting) Neglect or Acts of Omission (including failure to provide appropriate care, such as food, clothing, medication, heating, hygiene, and denying religious or cultural needs) Discriminatory Abuse (including racism, sexism, ageism, hate crimes and discrimination based on disabilities or sexual orientation) Modern Slavery (including human trafficking, forced labour and domestic servitude) Institutional Abuse (including neglect, poor care, inappropriate use of power, confinement, restraint, restriction, lack of choice and lack of personal clothing or possessions) Self-Harm (including withdrawal, excessive fear and physical harm to self) Self-Neglect (intentional poor hygiene, poor diet, etc.) Please provide any additional information on dates and times of concern here If the incident was reported by a third party, please enter the name of the witness and contact details if they are happy to be contacted by Prima Group or social services Please provide a summary of the concern below Please state facts only and, where possible, use the exact words of either the victim, witness or perpetrator. Additional Information Who reported the alleged incident or concern to you? * Witnessed by me Witnessed by another staff member Reported by a contractor Reported by phone Reported in-person to a staff member Other service provider (carer, utility company, etc.) Is the person at risk a Prima Group tenant? * Yes No - Household Occupant No - A Child of the Tenant No - Private Resident No - Family Member or Friend Unknown Other Is the person at risk aware of the referral being made? * Yes No Please enter any known details of the alleged perpetrator(s), such as name, address, relationship to person at risk Is the alleged perpetrator a Prima Group tenant? * Yes No Unknown Is there any reason to suggest staff should not visit the property alone? * Yes No If yes, please explain why Do you believe there is any ongoing risk to the person at risk or other members of the household? (Such as, children or other vulnerable adults) * Yes No Are there any further details you would like to include in your referral? Thank you.
