Person in a Position of Trust (PiPoT) Referral Form

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

Name

First Last

Phone

Date of referral

Time of referral

Has anyone been in immediate danger?

Yes

If yes, briefly state what actions were taken:

Name

First Last

Role/Employer

Work Location/Base:

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

Name/roles (or describe if unknown):

Name Role

Adults?

Children?

Both?

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

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

Has the PiPoT been informed?

Yes

Name

Date

Manager notified?

Yes

Date received

Reference number

Initial decision/outcome

Next Steps