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Central Bedfordshire Council
Accessibility Help
Safeguarding of Vulnerable Adults
Part 1
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Part 1
Items marked
must be completed
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Social Services ID No :
Crime Reference No:
NHS No:
Part 1 - Details of the adult at risk/vulnerable adult
Name:
Address:
Post code:
Date of Birth:
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February
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August
September
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November
December
Year
Gender:
Gender:
Male
Female
Ethnicity:
White British
White Irish
Black Caribbean
Black African
Indian
Pakistani
Bangladeshi
Chinese
Other
(Value If Not In List)
Date of alleged abuse:
Day
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Month
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
Time of alleged abuse:
:
Minute
(hours : minutes)
Preferred language or communication method?
English
Bengali
French
Italian
Polish
Punjabi
Spanish
Urdu
Other
(Value If Not In List)
Known Advocate, Family or Representative - provide details
Funding authority? (Local authority, Self, CHC, other, please state all that apply..)
If you are raising this on behalf of someone, have you discussed the concern with them?
If you are raising this on behalf of someone, have you discussed the concern with them?
Yes
No
You chose No - please explain why not?
Please state whether the person has mental capacity to understand the concern being raised.
Please state whether the person has mental capacity to understand the concern being raised.
Yes
No
Primary Client Group
Does the person have care and support needs arising from (Please tick)
Physical Disability, Frailty
Sensory Impairment:
Mental Health:
Learning Disability
Substance misuse:
Dementia
Other Vulnerable People e.g.
- Terminal/Palliative
- Unpaid Carer
Please state what:
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