GP Information Request Form

Nottingham City / Nottinghamshire County North / Nottinghamshire County South MARACs

Date of MARAC XXX and case number XXX
STRICTLY CONFIDENTIAL – Contains highly CONFIDENTIAL information
that should NOT be made visible for online patient access
Please ensure your details are fully completed in the table below and return this document via secure email / password protected to your
agency MARAC Representative by the date stated on the covering email. Please also retain a copy in the service user / patient records.
The record should be clearly marked as contains third party information and may contain information that could increase the risk if
disclosed. Many thanks for your co-operation.

To complete for cases open to your agency

NAME:
JOB TITLE:
GP Surgery:
CONTACT NUMBER:
EMAIL ADDRESS:

Your details may be shared at the MARAC if required to enable joint working and information updates
Details of any other professionals / agencies involved you
are aware of:

MARAC Case information:

Name Date of Birth Address
Survivor details
Perpetrator details
Children / Vulnerable adult

1
Nature of your involvement with the MARAC subjects within last 6 months- survivor/perpetrator/child-please specify.(e.g. length and quality of
engagement, frequency, last/next apt, reason for involvement / support provided and what work are you undertaking, current situation for the MARAC subject).

Current Information known about Safeguarding and/ or Domestic Abuse (within last 6 months) survivor/perpetrator/child-please specify
(e.g. child contact, breaches of orders, perpetrator history, current risks, pregnancy, patterns – increasing in severity and or frequency, harm to children,
Threats / attempts to kill, rape, disability, control or coercion, previous attempts to leave, issues to disclose, extreme jealousy, extreme levels of fear, use of
technology and or others to monitor and control, perpetrator risks e.g. loss of control and relationship and impact on their status / finances / reputation)

Brief summary of any historical Safeguarding or Domestic Abuse Concerns survivor/perpetrator/child-please specify

Any other risk information (Any other risks e.g. dogs, weapons, substance misuse, lone working issues, impact of any diagnosis or medication on risk,
cultural / immigration/ language barriers)

What actions do you think should / could be offered at the MARAC to help reduce risk and increase safety for the survivor, child(ren),
vulnerable adult and hold the perpetrator to account.

Many thanks for your co-operation.

Information can be shared under legal grounds for information sharing without consent if consent has not been provided such as Prevention and detection of crime
- s.115 Crime and Disorder Act 1998, To protect vital interests of the data subject; serious harm or matter of life or death - Schedule 8, DPA 2018, Overriding public
interest Common Law Right to life Right to be free from torture or inhuman or degrading treatment - Human Rights Act, Articles 2 & 3, Child protection. Disclosure
to Children’s Social Care or the Police for the exercise of functions - Children Act 1989 & 2004, Prevention of Abuse and Neglect - The Care Act 2014

2
Please ensure your details are fully completed at the top of this form and return this document via secure email / password protected to your agency MARAC
Representative by the date stated on the covering email.