Notifying CIW of Deprivation of Liberty (DoLS) request/authorisation 

Mae’r ffurflen gais hon hefyd ar gael yn Gymraeg / This application form is also available in Welsh

Information requested under Section 31(1) Care Standards Act 2000

This form can be used to notify CIW of Deprivation of Liberty Safeguards (DOLS) Authorisation requests. Guidance on completing and submitting this form is available on our website www.careinspectorate.wales 

Name of service user:	     	

Part 1: The establishment 
Name of service:	     
	
Address of service:	     
	
Part 2: Reason for notification
Office Use only:	Event:		Brief statement as to nature of event:	Date occurred:
(dd/mm/yyyy)	
	Deprivation of Liberty Safeguards (DOLS) Authorisation request:	     	     	
NOT39
	Urgent: 				
NOT40
	Standard: 				
	Outcome of request for Standard authorisation:		     	     	

Part 3: Others contacted
Organisation:
	Date contacted: (dd/mm/yyyy)	
Supervisory Body – Please specify the name of the supervisory authority for the DoLS authorisation request, the date the authorisation request was made and the contact telephone number for the supervisory body.      
	     	
Social Services Authority responsible for the individual – Please specify the authority name.       
	     	
Local Health Board responsible for the individual – Please specify the local health board name.      
	     	

Part 4: Form completed by:
Name:
	Job title:	Date: (dd/mm/yyyy)	
     	     	     	

Completed forms can be sent:

1.	By secure email to CIW.Support@gov.wales

2.	By Recorded Delivery to a CIW office:
Care Inspectorate Wales,         Government Buildings,
Sarn Mynach,
Llandudno Junction
LL31 9RZ                      Fax: 0872 437 7301	Care Inspectorate Wales, 
Welsh Government Building,
Rhydycar Business Park
Merthyr Tydfil
CF48 1UZ
Fax: 0872 437 7302	Care Inspectorate Wales         
Government Buildings
Picton Terrace
Carmarthen
SA31 3BT
Fax: 0872 437 7303	
Completed forms should be sent directly to CIW and not individually named staff 
For general enquiries please call 
0300 7900 126
Important: We process any personal and/or sensitive information we hold about you fairly and lawfully, and we only ask for such information where it is necessary for us to carry out our role. For more information about how we process your personal data, and your rights in relation to this, please see our Privacy Notice at https://careinspectorate.wales/how-we-use-your-information, or contact us for a paper copy.