AIS Number (if known)
NHS Number (if known)
RIO Number (if known)
Last name *
First name *
Traveller of Irish heritage
Any other white background
White and Black Caribbean
White and Black African
White and Asian
Any other mixed background
Any other Asian Background
Any other Black background
Any other Ethnic group
Information not yet obtained
Phone number area code
What is the preferred method of communication?
Date of birth (DD/MM/YYYY) *
Date of death (DD/MM/YYYY) - if applicable
Age band *
Has consent to share this information been given by the adult? *
If no, please explain why consent has not been given.
Is it safe to contact this person?
If no, please explain why it is not safe to contact this person.
Does the person require an independent advocate?
Do they have needs for care and support (whether or not the Local Authority is meeting any of those needs)
Are they experiencing, or at risk of, abuse or neglect
As a result of their care and support needs are they unable to protect themselves from either the risk of, or the experience of abuse or neglect?
Have there been any previous safeguarding issues with this person?
if yes, please give details of the previous safeguarding issues.