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Borough Council of King’s Lynn & West Norfolk

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Sanctuary Scheme referral

Completed by

Is this referral for:Is this referral for:

Yourself

Someone else

Referrer details

Please provide your contact details below.

You will be providing the full victim-survivor details in a later section.

Title

If other, please specify

First name

Surname

Phone number

Email address

Organisation

Information sharing and consent

The details that you provide on this form will be passed to the district's officer who administers the Sanctuary Scheme. This will allow them to carry out the initial property survey, the target hardening work, and where requested signposting to a relevant support provider. The information will be used for evaluation purposes only and no personal information will be shared unless in relation to this application.

I have read and accept the above statement.

I agree

I have read out the above statement to the victim-survivor.

I agree

Referral details

Reason for referral

When did the last incident occur?

What happened in the last incident?

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Perpetrator

Do youDoes the victim-survivor wish to provide perpetrator details?Do youDoes the victim-survivor wish to provide perpetrator details?

Yes

No

These have already been provided/recorded

Perpetrator details

Title (optional)

If other, please specify

First name

Surname

Age (or date of birth if known) (optional)

Postcode (optional)

Address name or number (optional)

Address line 1 (optional)

Address line 2 (optional)

Town/Village (optional)

Date they left the home (dd/mm/yyyy) (optional)

Is the perpetrator current serving time at HM Prison Service?Is the perpetrator current serving time at HM Prison Service? (optional)

Yes

Yes but due for release soon

No

Is there any further information youthe victim-survivor would like to provide? (optional)

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Safety details

Have youHas the victim-survivor been referred to MARAC?Have youHas the victim-survivor been referred to MARAC?

Yes

No

Is there a Police marker on the property?Is there a Police marker on the property?

Yes

No

Are youIs the victim-survivor receiving support from any of the following?Are youIs the victim-survivor receiving support from any of the following? (optional)

Name of Counselling agency

Contact details (if known) (optional)

Name of DV agency

Contact details (if known) (optional)

Name of mediation agency (optional)

Contact details (if known) (optional)

Name of victim-survivor support agency (optional)

Contact details (if known) (optional)

Name of other agency (optional)

Contact details (if known) (optional)

Any other information that would assist the person carrying out your target hardening? Please let us know if may be risks to staff involved in the target hardening of the property (from the perpetrator or anybody else). (optional)

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Privacy Notice

The Council has a duty to process and store your personal information safely and securely in line with data protection legislation, which here means the General Data Protection Regulations (Regulation (EC) 2016/679 which is in force from 25 May 2018) (GDPR) and any national implementing laws, regulations and secondary legislation, as amended or updated from time to time, in the UK and then any successor legislation to the GDPR.

The Borough Council of King’s Lynn and West Norfolk (the Council), of Kings Court, Chapel Street, King’s Lynn, Norfolk, PE30 1EX is the data controller for the purposes of the GDPR and associated domestic law.

We will use your personal information for the purposes of the provision of Sanctuary Scheme support. The processing of this information is necessary for the Council to undertake a public task, i.e. the processing is necessary for the Council to perform a task in the public interest or for its official functions.

Your data will be used for this specific purpose and will be passed to Sanctuary Scheme partner organisations (unless specified not to) who are contracted to undertake the early help on behalf of the Council. It may also be shared between Council departments and other agencies where there is lawful authority to do so.

Your information will be kept strictly confidential. It will be stored separately from other information in a secure, password-protected database on the Council’s computer system.

Your personal information will be kept for as long as you require Sanctuary Scheme support and for a period after the service is terminated. You can find more information about our retention policy on the privacy notice page. We will only use your data within the terms of data protection laws, will delete your data securely and only keep it for as long as necessary. We will review dates for keeping personal data in the future and if necessary update these privacy notices.

You may see copies of the data held about you and ask for it to be corrected or deleted.

You can find more information about Data Protection and the Council's Data Protection Officer, on our Data Protection page.

If you are unhappy with the way your personal information is being handled you can contact the Independent Information Commissioner.

Consent statement

Please ask the victim-survivor to read this consent statement carefully before submitting the form:

I certify to the best of my knowledge and belief, the information supplied on this form will be accurate.
I understand that by submitting the form, I will be agreeing for an assessment of their home in relation to some level of target hardening being required under the Sanctuary Scheme.
I understand the personal information collected on this form will be used by the Sanctuary Scheme to process my request, and deliver the service.
I understand the personal information may be disclosed to the Sanctuary Scheme partners in connection with delivering this service including installation of target hardening measures.
I agree for this data to be used for demonstating how the funding for the Sanctuary Scheme has been used, on the understanding that no personal details (such as names or addresses) will be used.
I understand that the information provided on this form is subject to the provisions of the General Data Protection Regulations (Regulation (EC) 2016/679 which is in force from 25 May 2018) (GDPR).

You can find out more detailed information about our Privacy Policy, on our privacy notice page.

I confirm that Ithe victim-survivor has agreed to the consent statement above and I understand that the information provided on this form is subject to the provisions of the above privacy notice.

I agree

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This scheme has been funded by the Department of Levelling Up, Housing and Communities through a grant made possible by Norfolk County Council.

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