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Case Management Panel Recording Form

Part 1

TO BE COMPLETED BY THE DESIGNATED SAFEGUARDING & PROTECTING CHILDREN LEAD OFFICER (CPO)

LEAD CHILD PROTECTION OFFICER DETAILS
Name  

 

Position  

 

Telephone

 

 
Mobile

 

 

 

 

Date Referral received

 

 
Case Number

 

 

 

DETAILS OF PERSON(S) INVOLVED IN REFERRAL (the accused)
Position (in relation to young person)  

 

 

DETAILS OF THE REFERRAL
Date/ time of referral

 

 
Location

 

 

 

 

Persons involved/ witnesses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nature of referral to include dates/time of concern/incident

 

 

 

 

 

 

 

 

 

 

 

How did the referral come to your attention?

 

 

 

Observations – e.g changes in behaviour, inappropriate actions, injuries, etc
 

 

 

 

 

 

 

Record of conversation – details of exactly what was said to you and by you

 

 

 

 

 

 

 

 

 

 

 

Action taken

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTACTS MADE
Persons contacted

(provide details of name and position and organisation, date and time contacted and any advice received)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SUMMARY
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ETHNIC GROUP

Please choose the category that best describes the child’s ethnic group if known, from the following list and tick the appropriate box

White
A1 British   A2 Irish  
A3 Any other white background      
Mixed
B1 White & Black Caribbean   B2 White & Black African  
B3 White & Asian   B4 Any other mixed background  
Asian
C1 Indian   C2 Pakistani  
C3 Bangladeshi   C4 Any other Asian background  
Black or Black British
D1 Caribbean   D2 African  
D3 Any other Black background      
Chinese or Other Ethnic Background
E1 Chinese      
E2 Any other (please write in)      

 

DISABILITY

The Disability Discrimination Act 1995 defines a disabled person as anyone with a “physical or mental impairment that has a substantial and long term adverse effect upon his/her ability to carry out normal day-to-day activities.

Please choose the description that best describes the nature of the child’s disability if relevant, and tick the appropriate box.

A Visually impaired   D Learning disability  
B Hearing impaired   E Multiple disability  
C Physical disability   F Other (Please write in)  

Part 2

TO BE COMPLETED BY MEMBERS OF THE SQUASH WALES CASE MANAGEMENT PANEL

Is there a case to answer?                                                                                      YES/NO

 

If YES, should this case be dealt with as a Summary Offence?                        YES/NO

 

Do you want to make any recommendations?                                                                YES/NO

 

 

Please record the recommendation that have been made to the Lead Officer on the route that this case should follow.  Please record the rationale behind the recommendation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Please log/attach any additional calls)

 

 

 

 

 

Details of members of the Case Management Panel involved in making this recommendation:

 

 

Name(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

Part 3

TO BE COMPLETED BY THE LEAD OFFICER

Details of actions taken and outcome (include all interim actions and outcomes)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signed ………………………………………………………………………………………….

 

Date …………………………………………………………………………………………….

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