Safeguarding Disclosure Form – inHope, Bristol

Safeguarding Policy – Disclosure Form

Safeguarding Policy – Disclosure Form CCM F044
This Disclosure Form is to be used in conjunction with Safeguarding Policy CCM P043.
This Form, with Sections 1~4 completed as far as possible, must be sent to the inHope Deputy
Safeguarding Officer (DSO) and the Safeguarding Officer (SO) at: safeguarding@inhope.uk
Essential: Do not investigate. A person noting a concern should focus only on establishing the basic
facts and ensuring immediate safety. Asking leading questions or attempting to find out 'the truth'
can compromise any subsequent formal Section 42 Safeguarding Enquiry or police investigation. The
core role is to record and report.
Date
Time

1. Details of the Person at Risk (the person causing you concern)
Name of individual causing
concern
(essential info)
Date of Birth (if known /
disclosed)
Age (if known / disclosed)
Address (if known /
disclosed)
Contact Number
(essential info)

2. Details of the Concern (the allegation or incident)
Describe the concern

•

•
•

•

Who (was
involved/alleged to
have caused harm - if
known),
What (happened/is
happening),
When (date, time, and
duration, including if it
is a single incident or a
pattern), Where
(location of the
incident or where the
abuse/neglect is
occurring), and
Why (any known
context or apparent
motive).
CCM F044 2_0

Printed copies will not be updated.

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Safeguarding Policy – Disclosure Form

(What exactly was seen,
heard, or reported? Use the
adult's own words if they
disclosed the information (or
the words of the person
reporting). Do not interpret
or summarise—record the
facts).
Details of any other
witnesses to this
information.

What category does the
concern fall under?
(e.g., Physical, Sexual,
Financial, Neglect,
Psychological, Domestic
Abuse, Self-Neglect, Modern
Slavery, etc.)
Location and description of
any visible marks, bruising
etc.

What impact do you observe
now on the individual
(e.g., injuries, distress,
change in behaviour,
financial loss).

Is the individual still in
immediate danger? Why?

Are other adults or children
at risk? Who?

CCM F044 2_0

Printed copies will not be updated.

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Safeguarding Policy – Disclosure Form

3. Details of the Alleged Source of Harm (If known)
Name of alleged abuser and
relationship to individual
causing concern (if known)
If alleged abuser is a
professional or volunteer,
record their
organisation/employer and
job title (if known)

4. Details of the Person Recording this concern
Was the information on this
Form completed in the
presence of the individual
causing concern?
Was any immediate action
taken to ensure the
individual's immediate
safety?

Yes

No

Yes

No

(e.g., called 999/101, sought
medical attention, informed
a manager).

Was consent to raise the
concern sought and/or given
by the individual?
Was the concern reported to
anyone within your
organisation?
(e.g., Safeguarding Officer,
Deputy Safeguarding Officer,
Supervisor).
Was the concern reported to
Bristol City Council (BCC)
Adult Social Care Team, and
if so, when?

CCM F044 2_0

Printed copies will not be updated.

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Safeguarding Policy – Disclosure Form
Did the BCC Adult Social Care
Team advise on further
action? If so, what?

Name of person completing
this Form
Signature of person
completing this Form
Date

5. Details of the Person Receiving this Disclosure Form
Name of Safeguarding
Officer (SO) or Deputy (DSO)
receiving this Form
Date this Disclosure Form
was received

6. Actions Taken by SO and/or DSO on Receipt of this Form
What actions, if any, were
taken by the SO or DSO, on
receipt of this Disclosure
Form?

CCM F044 2_0

Printed copies will not be updated.

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Safeguarding Policy – Disclosure Form

7. Details of the SO, or DSO Closing this Case
Is the SO or DSO satisfied
that the legal obligations of
inHope to an ‘Adult at Risk’
have been fulfilled?
Does the SO or DSO advise
that this Case can now be
closed?
Name of Safeguarding
Officer (SO) or Deputy (DSO)
Closing this Case

Yes

No

Yes

No

Yes

No

Is a review of the risks raised
by this Case required? If so,
when and by whom?

What lessons should be
noted for future practice
and/or policy?

Does the SO or DSO advise
that this Case has been
safely stored in inHope
records in compliance with
our data protection duties?
Signature of Safeguarding
Officer (SO) or Deputy (DSO)
closing this Case
Date Case Closed

CCM F044 2_0

Printed copies will not be updated.

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