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Wigan Council

Report concerns of abuse or neglect of a vulnerable adult

Your Details

Do not share my details with third parties (members of public only)

Reasons for remaining anonymous

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Name Organisation Telephone number Email What is your relationship to subject of this alert?

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Details of the person you are concerned about

Title Name Address

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Postcode Telephone number Gender Date of birth Do they have any communication needs?

Please give details of any communication needs

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GP Details

Surgery address

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Surgery telephone number

Consent

Is the person aware of this alert? Have they agreed to this alert being raised?

Please give details as to why they did not agree

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Do you have any reason to doubt the person’s capacity to agree to this alert being raised?

Please give details as to why you have doubts over their capacity to agree

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The person is being supported by

Details of person providing support

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Details of the incident / concern you have

Does the person continue to be at risk of harm? Type of abuse Source of possible risk or abuse Location / setting

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Details of all abuse (suspected or witnessed)

Date and time

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Brief factual details of the incident (This should include a clear factual outline of the concern being raised with details of people and places where appropriate)

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If injuries are present please give a brief / accurate description

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Any actions taken to date to safeguard individual?

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Was medical intervention required? YesNo Visit by GP? YesNo Taken to hospital? YesNo

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Tell us about the person who you think may be causing the abuse/harm

Name Date of birth Organisation name Address

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Do they live with the adult at risk? YesNoNot known Is the alleged source of risk the main carer? YesNoNot knownOther vulnerable adultIs a member of staff Any other information

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Are they aware that an alert has been raised? YesNoNot knownNot appropriate

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Report concerns of abuse or neglect of a vulnerable adult

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Your Details

Details of the person you are concerned about

GP Details

Consent

Details of the incident / concern you have

Details of all abuse (suspected or witnessed)

Tell us about the person who you think may be causing the abuse/harm