Under 5 Home Safety Check Referral Form

Parent/Carer Name

First NameLast Name

Email

example@example.com

Address:

Street Address

Townland

CityCounty

Post CodeCountry

Phone Number

Number and ages of child/ children in family

Referred by (Name and Contact Number)

Job Title

Organisation (please include health visiting team lead if applicable)

Please indicate how the family are eligible for free equipment: Please tick each that apply

Is this a priority referral? (i.e. should be seen within 7 working days).

YesNo

if yes, please provide details

What is the occupant’s first language?

EnglishOther

How well can the occupant speak/read/understand English?

Very wellWellNot wellNot at all

What is the occupant’s ethnic group?

Additional Comments (e.g. any other relevant matters the Home Safety Officer needs to be aware of?)

In accordance with the Data Protection Act 2018, Fermanagh and Omagh District Council has a duty to protect any information we hold on you.

The personal information you provide on this form will only be used for the purpose of the delivery of home accident prevention work and to produce statistical reports on the program. You are providing your personal data to the Council whose lawful basis for processing is for the performance of a task carried out in the public interest or in the exercise of official authority. The personal data will be shared externally with the Public Health Agency, and may be shared internally within the Council with staff who are involved in providing this service and, where necessary, between internal departments with the purpose of supporting an effective delivery of service.

We may also share your information with the relevant Health and Social Care Trust, Police Service of Northern Ireland or other Statutory and non-statutory bodies if we reasonably believe that it is necessary to protect your vital interests or those of another person. For further guidance on how we hold your information please visit the Privacy section at www.fermanaghomagh.com/your-council/privacy-statement/