Request Form for Strategy Meeting chaired by IRO or Quality and Review Manager

Name:

Role:

Team & District:

Contact Number:

What type of strategy meeting is being requested?

Choose an item.

Primary Category of Abuse

Choose an item.

If there is evidence of physical injury, has a medical examination been considered?

Yes ☐
No ☐

Has there been a strategy discussion with the Police on initial safeguarding measures?

Yes ☐
No ☐

Date of alleged incident

Who is the alleged victim?

SU Number

Name

Date of birth (format dd/mm/yy)

Sex

Male ☐

Female ☐

Legal status

Any other children involved/at risk of harm

Name

Date of birth (format dd/mm/yy)

Sex

Male ☐

Female ☐

Who is alleged to have caused the harm?

Name

Date of birth (format dd/mm/yy)

Sex

Male ☐

Female ☐

Information needed

If this is an FII Strategy request is there a health chronology?

Yes ☐
No ☐

If yes, please attach

Details of concerns

Where did the incident take place? (address and status, ie school, home, in the community)

Please provide a brief description of incident/allegation/concern

What has been the impact on the child/young person?

Do you believe there is evidence of significant harm?

Action already taken

Have previous strategy meetings been held in respect of this child/young person? If so, please provide brief details (dates, concerns, outcomes)

Invitees to Strategy Meeting

Please enter the following information in the box below for each invitee:

Name	Role	Agency	Contact Details

Form completed by

Date of completion