CONFIDENTIAL
(Version: May 2017) Form
SA2f
Safeguarding Adults
Request For A Case Conference Meeting
Adult At Risk:
Name:
Address:
ESCR ref:
Date of Birth:
Date of Death
(if applicable):
Ethnicity:
Gender:
Language:
Post Code:
Telephone No.
Summary of Safeguarding Concerns/Allegation:
< Guidance Notes: Please complete with the following:
Each alleged type of abuse to be stated (e.g. physical, domestic violence, sexual abuse,
psychological abuse, financial/material, modern slavery, discriminatory, neglect, organisational) as a
heading and numbered.
1. Under each alleged type of abuse, list key incident(s) that make up the allegation summarised as
numbered points
2. The estimated time frames for the Formal Enquiry Report to be finalised >
Date Safeguarding Concern Raised:
Date(s) of Strategy Meeting and any
Strategy Review Meetings:
Suggested Dates for Case Conference:
Date 1:
Date 2:
Date 3:
Suggested Venues:
Details Of Any Special Instructions or Specific Requirements
Case Conference meeting invites, a copy of the Formal Enquiry report and minutes will be sent to
people listed on the Case Conference Invitees List, unless advised otherwise here.
Requirements in relation to Invitations:
Requirements in relation to the Formal Enquiry Report:
Requirements in relation to circulation of Case Conference Minutes:
Form SA2f (Version: May 2017)
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Name and DoB of the Adult At Risk:
CONFIDENTIAL
Any other special needs or requirements:
Case Conference Invitees:
All people recorded here will be invited and be forwarded copies of the Formal Enquiry Report and
minutes, unless stated in the Special Instructions / Specific Requirements section:
Name
Relationship/Job Title
Email (or Postal Address) Phone Number
Safeguarding Coordinator
Enquiry Officer
Adult At Risk
Person alleged to have
caused harm
Adult At Risk / Person Alleged To Have Caused Harm
If the ‘adult at risk’ is not listed in the Case Conference Invitees Section, please state how their
views will be represented:
If the ‘person alleged to have caused harm’ is not listed in the Case Conference Invitees Section,
please state how their views will be represented:
NB: For the Case Conference Meeting to go ahead, the safeguarding Formal Enquiry report and
notes or minutes of strategy/strategy review meeting minutes) will need to be provided to the
Chair, 7 working days in advance of the Meeting. Please email these to
A&[email protected]
Form SA2f (Version: October 2014)
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Name and DoB of the Adult At Risk:
CONFIDENTIAL
Case Conference Requested by:
Name of Safeguarding Coordinator:
Email Address:
Phone Number:
To be Completed By Case Conference Chair:
Allocated Independent Case
Conference Chair:
Allocated Case Conference
Administrator:
Form SA2f (Version: October 2014)
Date Request Sent:
Date of allocation:
Date of allocation:
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