Professional allegation reporting form

Your contact details

Title *

If Other, please specify

Forename(s) *

Surname *

Telephone number *

Email address *

Do you know your manager's details? *

Yes

Your manager's name *

please complete either a telephone number or an email address or both if known

Telephone number *

Email address *

Referring agency details

Your establishment name *

Establishment address

Search for an address *

(If your PostCode / Address is outside Stockport area or is shown incorrectly please click 'Enter Manually'.)

House Name or Number *

Street *

Locality

Town *

Postcode *

Person who has made the allegation details

Name of the person making the allegation

What date was the allegation reported to you? *

Allegation time reported (If known)

Name of the person to whom the allegation was made? *

Please provide any other background information about the setting of the incident which you think would be useful

Details about the young person(s) subject to the incident

Forename

Surname

Gender

Date of birth

Address

Additional details of young person

Does the young person have a social worker?

Yes No Not Known

Social worker forename *

Social worker surname *

Social worker local authority *

please complete either a telephone number or an email address or both if known

Social worker telephone number *

Social worker email address *

Does the child have a disability?

Yes No Not known

Please provide as much information as possible*

Are there any more children involved?

Yes No Not known

Please provide as much information as possible in the same format as above (full name, gender, DOB, address, details of social worker and any disability) *

Personal details of the adult subject to the allegation

Forename

Surname

Gender

Date of birth

Address

Employment details of adult subject to the allegation

Establishment name

Address

Occupation

Does the adult, subject to the allegation, have contact with children outside of the workplace / voluntary organisation?

Yes No Not Known

Please provide Name of Organisation/ Job Title in Organisation / Contact Details of Organisation *

Does the adult subject to the allegation have their own children and / or significant care responsibilities for children within friends and / or family networks?

Yes No Not Known

Please provide Name of child/ren / Date of Birth or Age / Relationship to adult subject to the allegation / Parents’ name, address and telephone number *

Incident details

Incident date

Incident time (If known)

Please describe what happened and why you are concerned *

Were there any triggers? *

Yes No

Please give details of triggers *

Was there a restraint? *

Yes No

Please give details of restraint *

What action, if any, has been taken by the employer? *

Is there any evidence to substantiate the allegation? *

Yes No

Please give details of evidence *

Were there any witnesses? *

Yes No

Please provide information about any wintnesses to the incident, including (where possible) their name/address/role and relationship to the adult and child involved in the Incident *

Has this incident been reported to any other agency (e.g. OLA LADO, Police, Local Authority etc.)? *

Yes No

Please provide information about any reports made in regard to the Incident *

Evidence file(s) to be added / uploaded

Evidence file one

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Evidence file two

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Evidence file three

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