Restricted
Adult and Community Services
ALERT TO THE SAFEGUARDING ADULTS TRIAGE TEAM
Please ensure that the information you provide is as detailed as possible to allow Triage to prioritise alerts
(according to the level of risk) and respond appropriately.
Note: This form is designed to be completed electronically as the boxes expand to allow free typing.
Return to Triage via
Email: dorsetadultsafeguarding@dorsetcc.gcsx.gov.uk or Fax: 01929 554217
Date of reporting this alert to Triage:
Date and time of incident:
 Name of person reporting incident
 Contact number
 Position held
 Organisation/Team details
Please complete details for both the adult at
risk and for person/persons alleged to have
caused harm
 Full Name
Adult at risk
Person(s) alleged to
have caused harm
 Date of Birth
 Address
AIS Person Identifier Number (if known)
Nature of vulnerability/disability of both
parties (e.g. dementia, head injury, learning
disability)
Length of time both parties have resided at
the location/received the service
(if applicable)
Funding status of both parties (e.g. selffunded, CHC, funded by another authority)
 For those who do not have capacity:
have relatives been informed (where
appropriate and in their best
interest)?
 For those who have capacity: do
they wish for their relative/
representative to be involved?
SA25 (02/13)
DL
Details of the incident: please be as clear as
possible, stating actions of person alleged to
have caused harm (where appropriate)
and/or exact circumstances.
Continue on another sheet if necessary
and/or include any witness statements
(however, do not initiate an investigation – if
in doubt, please contact Triage)
Please state where the incident occurred
(e.g. own home, hospital, Residential/
Nursing home, temporary place of
residence, supported housing). If hospital,
please give ward name and date of
admission/discharge
Location of incident (e.g. lounge area,
bedroom, kitchen)
Have you raised (or are you aware of) any
previous safeguarding adults’ alerts
concerning this adult at risk?
Have there been any previous incidents
between these parties and/or incidents
involving the person alleged to have caused
harm? If so, how many? Please give brief
details
Are there any injuries? Please provide body
map (where appropriate)
 State details of any injuries
 State immediate action taken
Has medical attention been sought where
appropriate? Please provide details
SA25 (07/11)
DL
Please describe the mental capacity of the
adult at risk
 Are they able to understand what
has occurred?
 Have they consented to the
safeguarding alert?
Please describe the mental capacity of the
person alleged to have caused harm
 Are they able to understand what
has occurred and the potential
consequences?
If they are able to say, what outcome does
the alleged adult at risk want?
Details of any witnesses and whether
witness accounts have been obtained.
If so, please attach a copy
Please detail what immediate action has
1.
been taken to safeguard the adult at risk and
any other adults/children at risk
2.
(if appropriate)
3.
4.
5.
Where appropriate, what action is intended
in order to prevent future, similar incidents?
If a serious crime is alleged or suspected the
Police should be contacted immediately,
followed by an alert to Dorset County
Council Triage.
Please detail all contact with the police and
include crime reference number
SA25 (07/11)
DL