Adult Protective Services

Note: Any fields with * are required

VICTIM

If victim's name is unknown, please enter "Unknown."

First Name:

Middle Name:

*Last Name:

* Please enter Age or Date of Birth:

Age (or approx. age):

Exact Age Unknown

DOB:

SSN:

Invalid social security number. Example 1 2 3 - 4 5 - 6 7 8 9

Language:

Speaks English:

Race:

Ethnicity:

Gender:

Sexual Orientation:

Living Arrangements:

Address:

City:

Zip Code:

Primary Phone:

Home Phone:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0

Work Phone:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0 ext:

Cell/Other:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0

Current Location: (if different from address)

Physical/Mental Impairments (if under 65):

SUSPECTED ABUSER #1 (If self, please skip to reporting party.)

First Name:

*Last Name:

Age:

DOB:

SSN:

Invalid social security number. Example 1 2 3 - 4 5 - 6 7 8 9

Gender:

Ethnicity:

Race:

Collateral Type:

Resource Type:

Relation to AV:

Weight:

lbs

Height:

ft in

Eyes:

Hair:

Address Line 1:

Lives with client

Address Line 2:

City:

State: Zip Code: -

Primary Phone:

Home Phone:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0

Work Phone:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0 ext:

Cell/Other:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0

SUSPECTED ABUSER #2 (If self, please skip to reporting party.)

First Name:

Last Name:

Age:

DOB:

SSN:

Invalid social security number. Example 1 2 3 - 4 5 - 6 7 8 9

Gender:

Ethnicity:

Race:

Collateral Type:

Resource Type:

Relation to AV:

Weight:

lbs

Height:

ft in

Eyes:

Hair:

Address Line 1:

Lives with client

Address Line 2:

City:

State: Zip Code: -

Primary Phone:

Home Phone:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0

Work Phone:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0 ext:

Cell/Other:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0

SUSPECTED ABUSER #3 (If self, please skip to reporting party.)

First Name:

Last Name:

Age:

DOB:

SSN:

Invalid social security number. Example 1 2 3 - 4 5 - 6 7 8 9

Gender:

Ethnicity:

Race:

Collateral Type:

Resource Type:

Relation to AV:

Weight:

lbs

Height:

ft in

Eyes:

Hair:

Address Line 1:

Lives with client

Address Line 2:

City:

State: Zip Code: -

Primary Phone:

Home Phone:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0

Work Phone:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0 ext:

Cell/Other:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0

REPORTING PARTY (Person completing this form)

*First Name:

*Last Name:

Gender:

Ethnicity:

Race:

*Collateral Type:

Resource Type:

*Relation to AV:

Email:

Work Place:

Occupation:

Primary Phone:

Home Phone:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0

Work Phone:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0 ext:

Cell/Other:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0

Best time of day to reach you (25 chars max):

Address Line 1:

Lives with client

Address Line 2:

City:

State:

Zip Code:

INCIDENT INFORMATION

Date and Time of this incident: :

*Address:

Incident Address Line 1:

Incident Address Line 2:

Incident City:

Incident State:

Incident Zip Code:

Phone Number: Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0

Incident Occurred At: Incident Other:

Select the institution reporting (if applicable):

Facility:

REPORTED TYPES OF ABUSE (check all that apply)

Abuse Resulted In:

If Other, please specify:

Self Neglect Allegations:

Financial	Health & Safety
Malnutrition/Dehydration	Medical Care

If Other, please specify:

Abuse Perpetrated by Others:

Abuse	Material or Financial Abuse/Exploitation
Neglect	Psychological/Emotional Abuse

If Other, please specify:

Physical Abuse:

Sexual Abuse

*What happened today that led you to make this report?(Observations, beliefs, statements made by victim)(2000 characters max)

Does the Suspected Abuser still have access to the victim?

Access to alleged victim options

Yes

If Yes, explain. Provide any known time frame (2 days, 1 week, ongoing etc.) (500 characters max)

If the Alleged Victim is under 65, please describe their cognitive and/or physical limitations. (Do they need a caregiver to meet their basic daily needs? Are they wheelchair dependent? What current third party assistance are you aware of for this person?) (500 characters max)

*Is there a potential danger to the investigating worker, or other problem with access? (guns, animals, recent violence etc.)

Potential danger to investigating worker options

Yes

If Yes, please specify (500 characters max)

TARGETED ACCOUNT

Targeted Account Information:

Account Number:

(last 4 digits)

Type of Account:

Type of Account CreditDepositOther

Trust Account:

Trust Account YesNo

Power of Attorney:

Power of Attorney YesNo

Direct Deposit:

Direct Deposit YesNo

Other Accounts:

Other Accounts YesNo

OTHER PERSONS BELIEVED TO HAVE KNOWLEDGE OF ABUSE.
FAMILY MEMBER OR OTHER PERSON RESPONSIBLE FOR VICTIM'S CARE. (If unknown, list contact person)

First Name:

Last Name:

DOB:

SSN:

Invalid social security number. Example 1 2 3 - 4 5 - 6 7 8 9

Collateral Type:

Relation to AV:

Resource Type:

Gender:

Race:

Address Line 1:

Lives with client

Address Line 2:

City:

State: Zip Code: -

Primary Phone:

Home Phone:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0

Work Phone:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0 ext:

Cell/Other:

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0

Other Agency Information (Please answer if law enforcement has been contacted.)

Has law enforcement been contacted?

Has law enforcement been contacted

Yes

Agency

First Name

Last Name

Number

Date

Invalid phone number. Example ( 1 2 3 ) 4 5 6 - 7 8 9 0

Please provide any other information that would help us investigate:

* The report I am submitting does not require an emergency response.

* I understand that if I did not see a confirmation message that my report was submitted, I must check for errors or
incomplete entries on the form.

All of this information is confidential and no results or updates from this report can or will be provided back to the referent

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