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Person in a Position of Trust (PiPoT) Referral Form

Person in a Position of Trust (PiPoT) Referral Form

For reporting safeguarding concerns about a Person in a Position of Trust.

1. Referrer Details - Complete Sections 1-8 below

Name

First Last

Email

Phone

Date of referral

Time of referral

:

Has anyone been in immediate danger?

Yes

No

If yes, briefly state what actions were taken:

2. PiPoT Details

Name

First Last

3. Summary of Concern

Provide a brief factual description of the concern/allegation (what happened, when, where, who was involved):

4. Who May Be at Risk

Name/roles (or describe if unknown):

Name Role

Adults?

Children?

Both?

5. Evidence or Information Available

Please provide any evidence or information available (e.g. email, message, statement, observation)

6. Information sharing

Has the PiPoT been informed?

Yes

No

8. Referrer Declaration - I confirm this information is accurate to the best of my knowledge

Name

Date

Manager notified?

Yes

No

To submit this form please click the SUBMIT button

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9. For Safeguarding Team Use Only

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Immediate Actions Taken - internal use only

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Please provide details about the immediate actions taken (e.g. informed manager, moved staff member, contacted Police/LADO/LA Safeguarding)

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Date received

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Reference number

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Initial decision/outcome

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Next Steps

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