Information sharing without consent form Name and DOB of Survivor Address Children Who is at Risk? DOB Address Immediate risk/crisis School (if known) Risk identified through risk assessment Risk/danger to child(ren) Risk/Danger to survivor Risk/Danger to Vulnerable Adult Client poses a risk to self or others Have you asked for consent to share information: Yes / No Escalation in Severity and Frequency of abuse? Yes / No Professional Judgment: Yes / No Repeat Marac Case? Yes / No Risk Identification Checklist (if it has been possible to complete a SafeLives DASH RIC, attach it here) / 24 (number of ticks) Details of incident / information causing concern (include source of information) Web www.safelives.org.uk E-mail [email protected] Tel 0117 4033 220 © SafeLives 2016. Please acknowledge SafeLives when reprinting. Registered charity number 1106864. 1 Legal Authority to Share Protocol relevant Y / N If yes, please detail Or Legal grounds (If yes, please tick one or more grounds below) Y/N Prevention / detection or crime and/or apprehension or prosecution of offenders (DPA, sch 29) To protect vital interests of the data subject; serious harm or matter of life or death (DPS, sch 2 & 3) For the administration of justice (usually bringing perpetrators to justice (DPA, sch 2 & 3) For the exercise of functions conferred on any person by or under any enactment (police / Social Services) (DPA, sch 2 & 3) In accordance with a court order Local Authority Enquiry under Care Act 2014 Prevention of abuse and neglect The Care Act 2014 Overriding public interest (common law) Child protection – disclosure to social services or police for the exercise of functions under the children act, where the public interest in safeguarding the child’s welfare overrides the need to keep the information confidential (DPA, sch 2 & 3) Right to life (Human Rights Act, art. 2 & 3) Right to be free from torture, of inhuman or degrading treatment (Human Rights Act, art. 2 & 3) Balancing Considerations (please tick) Pressing need Risk of not disclosing Respective risks to those affected Interest of other agency / person in receiving it Public interest of disclosure Human rights Duty of confidentiality Other Comments Internal consultations (Names / Dates / Advice / Decisions) External consultations (Home Office, Information Sharing Helpline) Survivor Notification Client notified Y/N Date notified Web www.safelives.org.uk E-mail [email protected] Tel 0117 4033 220 © SafeLives 2016. Please acknowledge SafeLives when reprinting. Registered charity number 1106864. 2 If not, why not? Review Date for review of situation (review to include feedback from the agencies informed as to their response) Name of person responsible for ensuring the situation is reviewed by this date Record the following information-sharing in case file: Date information shared Agency & named person informed Method of contact Legal authority for each agency Signature of caseworker Date (as signed by caseworker) Signature of manager Date (as signed by manager) Web www.safelives.org.uk E-mail [email protected] Tel 0117 4033 220 © SafeLives 2016. Please acknowledge SafeLives when reprinting. Registered charity number 1106864. 3

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