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Client Information
*
First Name:
Middle Name:
*
Last Name:
*
DOB:
OR
Age:
Exact Age Unknown
SSN:
###-##-####
Language:
-- Please Select --
Amharic
Arabic
Armenian
Assistive technology
Cambodian
Cantonese
Chinese
English
Farsi
French
German
Hebrew
Hmong
Italian
Japanese
Karen
Korean
Lao
Llacano
Mandarin
Mien
Not Assigned
Oromo
Other Chinese
Other non-English
Polish
Portuguese
Russian
Samoan
Sign Language American
Sign Language Other
Spanish
Tagalog
Thai
Turkish
Unknown
Vietnamese
Speaks English
Ethnicity:
-- Please Select --
Asian
Hispanic or Latino/a or Spanish Origin
Mexican or Mexican American
Native American
Not Assigned
Not Hispanic, Latino/a or Spanish Origin
Other Hispanic or Spanish Origin
Puerto Rican
Race:
-- Please Select --
Black or African-American
Cambodian
Chinese
Filipino
Guamanian or Chamorro
Hawaiian
Hispanic
Japanese
Korean
Loatian
Native American
Native Hawaiian or Other Pacific Islander
Not Assigned
Other
Other Asian
Samoan
Vietnamese
White
Gender:
-- Please Select --
Female
Male
Not Assigned
Not Listed
Trans-Man
Trans-Woman
Unknown
Sexual Orientation:
-- Please Select --
Bisexual
Gay/Lesbian
Not Assigned
Other
Straight
Living Arrangements:
-- Please Select --
Hospital/Acute Care Hospital
Apartment
Assisted Living Facility
Community Support Provider/Group Home
Deceased
Home/Apt. of others
Homeless
Hotel
Not Assigned
Other
Own Home
Own Home - Lives Alone
Own Home - Lives with Others
Room and Board
Skilled Nursing Facility
Unknown
Address:
City:
Zip Code:
Primary Phone:
-- Please Select --
Home Phone
Work Phone
Cell/Other Phone
Home Phone :
Work Phone :
Cell/Other Phone:
Current Location: (if different from address)
Physical/Mental Impairmants (if under 65)
Reported Types Of Abuse (Check All That Apply)
*Required
Abuse Resulted In:
Death
Hospitalization
Mental Suffering
Minor Medical Care
No Physical Injury
Other
Required medical attention
Serious Bodily Injury
Unknown
If Other, please specify:
Self Neglect Allegations:
Financial
Health & Safety
Malnutrition/Dehydration
Medical Care
If Other, please specify:
Abuse Perpetrated by Others:
Abuse
Sexual Abuse
Material or Financial Abuse/Exploitation
Neglect
Psychological/Emotional Abuse
If Other, please specify:
Suspected Abuser #1
First Name:
*
Last Name:
Gender:
-- Please Select --
Female
Male
Not Assigned
Not Listed
Trans-Man
Trans-Woman
Unknown
Collateral Type:
-- Please Select --
211 Helpline
988 Suicide/Crisis Line
Administrator/owner/operator
Adult Day Care Provider/Staff
Anonymous
Apartment Manager
APS Worker
Area Agency on Aging
Assisted Living Facility
Attorney
Bank Manager
Bank or Credit Union Staff
Board & Care Home Provider/Staff
Brokerage employee
Caregiver
Case Mgr
Child Protective Services (CPS)
Chiropractor
Clergy
Client
Community Center Staff
Consumer Protection
Contact Person Only
Counselor or therapist
Dental Provider or staff
Direct care staff
Discharge planner/hospital
District Attorney
Domestic violence center
Eligibility SW or Staff
EMT or Rescue Personnel
ER Staff/Doctor/Nurse
Family
Fiduciary
Financial Institution
Financial Manager employee
Financial Services Provider, other
Firefighter/Fire Department Other
First responder
Former care provider
Friend/Neighbor
Guardian
Health Provider
Home Delivered Meals staff
Home health provider/staff
Hospice provider
Hospital
Housing Code Enforcement Staff
IHSS SW/Staff
Insurance Provider or Staff
Judge
Landlord or Employee of Client Residence
Law and Code Enforcement/Legal Provider
Law enforcement
Licensed practical nurse
Meal Provider
Medical Clinic Provider
Medical examiner
Medical Technician
Medical Transportation
Mental health professional
Money Manager
MRT
Neighbor
Not Assigned
Nurse
Nurse aid
Nursing home staff
Occupational or Physical Therapist
Ombudsman
Other
Other Code Enforcement Staff
Other County/State Program staff
Other Organization Staff
Paid caregiver
Paramedic
Pharmacist
Physician
Physician Assistant
Probate Court
Public Authority/Staff
Public Education Staff
Public Guardian/Administrator
Public transportation driver
Regional Center Provider
Religious adviser or religious staff
Repair person
Retail
Roommate/Housemate
Sales
Self
Service Coordinator
Social Service Provider
Social worker/social services staff
Sr Service Agency Provider
State agency employee
Telemarketer
Tenant
Tribal Protection
Tribal social worker
Unassigned
Utility representative
Veterans Services Staff
Visitor
Resource Type:
-- Please Select --
Caretaker
Conservator
Durable Power of Attorney
Legal guardian and/or estate
Legal guardian of the estate
Legal guardian of the person
Mandated Reporter
Mental Health Provider
Next of kin
No known legal relationship
Non-Mandated Reporter
Not Assigned
Other
Power of attorney
Representative payee
Self
Trustee
Unassigned
Relation to Victim:
-- Please Select --
Aunt
Brother
Cousin
Daughter
Ex-spouse
Father
Granddaughter
Grandparent
Grandson
Husband
In-law
Medical Staff
Minor Child
Mother
Nephew
Niece
None
Not Assigned
Other family
Partner or Domestic Partner
Self
Significant Other
Sister
Son
Spouse
Step-parent
Stepchild
Uncle
Unknown
Wife
Address:
Lives with client
SSN
###-##-####
City:
State:
-- Please Select --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
-
Primary Phone:
-- Please Select --
Home Phone
Work Phone
Cell/Other Phone
Home Phone:
Work Phone:
Cell/Other Phone:
DOB:
OR
Age:
Ethnicity:
-- Please Select --
Asian
Hispanic or Latino/a or Spanish Origin
Mexican or Mexican American
Native American
Not Assigned
Not Hispanic, Latino/a or Spanish Origin
Other Hispanic or Spanish Origin
Puerto Rican
Race:
-- Please Select --
Black or African-American
Cambodian
Chinese
Filipino
Guamanian or Chamorro
Hawaiian
Hispanic
Japanese
Korean
Loatian
Native American
Native Hawaiian or Other Pacific Islander
Not Assigned
Other
Other Asian
Samoan
Vietnamese
White
Eyes:
Hair:
Weight:
Height:
Suspected Abuser # 2
First Name:
*Last Name:
Gender:
-- Please Select --
Female
Male
Not Assigned
Not Listed
Trans-Man
Trans-Woman
Unknown
Collateral Type:
-- Please Select --
211 Helpline
988 Suicide/Crisis Line
Administrator/owner/operator
Adult Day Care Provider/Staff
Anonymous
Apartment Manager
APS Worker
Area Agency on Aging
Assisted Living Facility
Attorney
Bank Manager
Bank or Credit Union Staff
Board & Care Home Provider/Staff
Brokerage employee
Caregiver
Case Mgr
Child Protective Services (CPS)
Chiropractor
Clergy
Client
Community Center Staff
Consumer Protection
Contact Person Only
Counselor or therapist
Dental Provider or staff
Direct care staff
Discharge planner/hospital
District Attorney
Domestic violence center
Eligibility SW or Staff
EMT or Rescue Personnel
ER Staff/Doctor/Nurse
Family
Fiduciary
Financial Institution
Financial Manager employee
Financial Services Provider, other
Firefighter/Fire Department Other
First responder
Former care provider
Friend/Neighbor
Guardian
Health Provider
Home Delivered Meals staff
Home health provider/staff
Hospice provider
Hospital
Housing Code Enforcement Staff
IHSS SW/Staff
Insurance Provider or Staff
Judge
Landlord or Employee of Client Residence
Law and Code Enforcement/Legal Provider
Law enforcement
Licensed practical nurse
Meal Provider
Medical Clinic Provider
Medical examiner
Medical Technician
Medical Transportation
Mental health professional
Money Manager
MRT
Neighbor
Not Assigned
Nurse
Nurse aid
Nursing home staff
Occupational or Physical Therapist
Ombudsman
Other
Other Code Enforcement Staff
Other County/State Program staff
Other Organization Staff
Paid caregiver
Paramedic
Pharmacist
Physician
Physician Assistant
Probate Court
Public Authority/Staff
Public Education Staff
Public Guardian/Administrator
Public transportation driver
Regional Center Provider
Religious adviser or religious staff
Repair person
Retail
Roommate/Housemate
Sales
Self
Service Coordinator
Social Service Provider
Social worker/social services staff
Sr Service Agency Provider
State agency employee
Telemarketer
Tenant
Tribal Protection
Tribal social worker
Unassigned
Utility representative
Veterans Services Staff
Visitor
Resource Type:
-- Please Select --
Caretaker
Conservator
Durable Power of Attorney
Legal guardian and/or estate
Legal guardian of the estate
Legal guardian of the person
Mandated Reporter
Mental Health Provider
Next of kin
No known legal relationship
Non-Mandated Reporter
Not Assigned
Other
Power of attorney
Representative payee
Self
Trustee
Unassigned
Relation to Victim:
-- Please Select --
Aunt
Brother
Cousin
Daughter
Ex-spouse
Father
Granddaughter
Grandparent
Grandson
Husband
In-law
Medical Staff
Minor Child
Mother
Nephew
Niece
None
Not Assigned
Other family
Partner or Domestic Partner
Self
Significant Other
Sister
Son
Spouse
Step-parent
Stepchild
Uncle
Unknown
Wife
Address:
Lives with client
SSN
###-##-####
City:
State:
-- Please Select --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
-
Primary Phone:
-- Please Select --
Home Phone
Work Phone
Cell/Other Phone
Home Phone:
Work Phone :
Cell/Other Phone:
DOB:
OR
Age:
Ethnicity:
-- Please Select --
Asian
Hispanic or Latino/a or Spanish Origin
Mexican or Mexican American
Native American
Not Assigned
Not Hispanic, Latino/a or Spanish Origin
Other Hispanic or Spanish Origin
Puerto Rican
Race:
-- Please Select --
Black or African-American
Cambodian
Chinese
Filipino
Guamanian or Chamorro
Hawaiian
Hispanic
Japanese
Korean
Loatian
Native American
Native Hawaiian or Other Pacific Islander
Not Assigned
Other
Other Asian
Samoan
Vietnamese
White
Eyes:
Hair:
Weight:
Height:
-
Suspected Abuser # 3
First Name:
*Last Name:
Gender:
-- Please Select --
Female
Male
Not Assigned
Not Listed
Trans-Man
Trans-Woman
Unknown
Collateral Type:
-- Please Select --
211 Helpline
988 Suicide/Crisis Line
Administrator/owner/operator
Adult Day Care Provider/Staff
Anonymous
Apartment Manager
APS Worker
Area Agency on Aging
Assisted Living Facility
Attorney
Bank Manager
Bank or Credit Union Staff
Board & Care Home Provider/Staff
Brokerage employee
Caregiver
Case Mgr
Child Protective Services (CPS)
Chiropractor
Clergy
Client
Community Center Staff
Consumer Protection
Contact Person Only
Counselor or therapist
Dental Provider or staff
Direct care staff
Discharge planner/hospital
District Attorney
Domestic violence center
Eligibility SW or Staff
EMT or Rescue Personnel
ER Staff/Doctor/Nurse
Family
Fiduciary
Financial Institution
Financial Manager employee
Financial Services Provider, other
Firefighter/Fire Department Other
First responder
Former care provider
Friend/Neighbor
Guardian
Health Provider
Home Delivered Meals staff
Home health provider/staff
Hospice provider
Hospital
Housing Code Enforcement Staff
IHSS SW/Staff
Insurance Provider or Staff
Judge
Landlord or Employee of Client Residence
Law and Code Enforcement/Legal Provider
Law enforcement
Licensed practical nurse
Meal Provider
Medical Clinic Provider
Medical examiner
Medical Technician
Medical Transportation
Mental health professional
Money Manager
MRT
Neighbor
Not Assigned
Nurse
Nurse aid
Nursing home staff
Occupational or Physical Therapist
Ombudsman
Other
Other Code Enforcement Staff
Other County/State Program staff
Other Organization Staff
Paid caregiver
Paramedic
Pharmacist
Physician
Physician Assistant
Probate Court
Public Authority/Staff
Public Education Staff
Public Guardian/Administrator
Public transportation driver
Regional Center Provider
Religious adviser or religious staff
Repair person
Retail
Roommate/Housemate
Sales
Self
Service Coordinator
Social Service Provider
Social worker/social services staff
Sr Service Agency Provider
State agency employee
Telemarketer
Tenant
Tribal Protection
Tribal social worker
Unassigned
Utility representative
Veterans Services Staff
Visitor
Resource Type:
-- Please Select --
Caretaker
Conservator
Durable Power of Attorney
Legal guardian and/or estate
Legal guardian of the estate
Legal guardian of the person
Mandated Reporter
Mental Health Provider
Next of kin
No known legal relationship
Non-Mandated Reporter
Not Assigned
Other
Power of attorney
Representative payee
Self
Trustee
Unassigned
Relation to Victim:
-- Please Select --
Aunt
Brother
Cousin
Daughter
Ex-spouse
Father
Granddaughter
Grandparent
Grandson
Husband
In-law
Medical Staff
Minor Child
Mother
Nephew
Niece
None
Not Assigned
Other family
Partner or Domestic Partner
Self
Significant Other
Sister
Son
Spouse
Step-parent
Stepchild
Uncle
Unknown
Wife
Address:
Lives with client
SSN
###-##-####
Primary Phone:
-- Please Select --
Home Phone
Work Phone
Cell/Other Phone
Home Phone:
Work Phone:
Cell/Other Phone:
City:
State:
-- Please Select --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
-
DOB:
OR
Age:
Ethnicity:
-- Please Select --
Asian
Hispanic or Latino/a or Spanish Origin
Mexican or Mexican American
Native American
Not Assigned
Not Hispanic, Latino/a or Spanish Origin
Other Hispanic or Spanish Origin
Puerto Rican
Race:
-- Please Select --
Black or African-American
Cambodian
Chinese
Filipino
Guamanian or Chamorro
Hawaiian
Hispanic
Japanese
Korean
Loatian
Native American
Native Hawaiian or Other Pacific Islander
Not Assigned
Other
Other Asian
Samoan
Vietnamese
White
Eyes:
Hair:
Weight:
Height:
-
+ Add Another
Reporting Party
*
First Name:
*
Last Name:
Gender:
-- Please Select --
Female
Male
Not Assigned
Not Listed
Trans-Man
Trans-Woman
Unknown
Ethnicity:
-- Please Select --
Asian
Hispanic or Latino/a or Spanish Origin
Mexican or Mexican American
Native American
Not Assigned
Not Hispanic, Latino/a or Spanish Origin
Other Hispanic or Spanish Origin
Puerto Rican
Race:
-- Please Select --
Black or African-American
Cambodian
Chinese
Filipino
Guamanian or Chamorro
Hawaiian
Hispanic
Japanese
Korean
Loatian
Native American
Native Hawaiian or Other Pacific Islander
Not Assigned
Other
Other Asian
Samoan
Vietnamese
White
*
Collateral Type:
-- Please Select --
211 Helpline
988 Suicide/Crisis Line
Administrator/owner/operator
Adult Day Care Provider/Staff
Anonymous
Apartment Manager
APS Worker
Area Agency on Aging
Assisted Living Facility
Attorney
Bank Manager
Bank or Credit Union Staff
Board & Care Home Provider/Staff
Brokerage employee
Caregiver
Case Mgr
Child Protective Services (CPS)
Chiropractor
Clergy
Client
Community Center Staff
Consumer Protection
Contact Person Only
Counselor or therapist
Dental Provider or staff
Direct care staff
Discharge planner/hospital
District Attorney
Domestic violence center
Eligibility SW or Staff
EMT or Rescue Personnel
ER Staff/Doctor/Nurse
Family
Fiduciary
Financial Institution
Financial Manager employee
Financial Services Provider, other
Firefighter/Fire Department Other
First responder
Former care provider
Friend/Neighbor
Guardian
Health Provider
Home Delivered Meals staff
Home health provider/staff
Hospice provider
Hospital
Housing Code Enforcement Staff
IHSS SW/Staff
Insurance Provider or Staff
Judge
Landlord or Employee of Client Residence
Law and Code Enforcement/Legal Provider
Law enforcement
Licensed practical nurse
Meal Provider
Medical Clinic Provider
Medical examiner
Medical Technician
Medical Transportation
Mental health professional
Money Manager
MRT
Neighbor
Not Assigned
Nurse
Nurse aid
Nursing home staff
Occupational or Physical Therapist
Ombudsman
Other
Other Code Enforcement Staff
Other County/State Program staff
Other Organization Staff
Paid caregiver
Paramedic
Pharmacist
Physician
Physician Assistant
Probate Court
Public Authority/Staff
Public Education Staff
Public Guardian/Administrator
Public transportation driver
Regional Center Provider
Religious adviser or religious staff
Repair person
Retail
Roommate/Housemate
Sales
Self
Service Coordinator
Social Service Provider
Social worker/social services staff
Sr Service Agency Provider
State agency employee
Telemarketer
Tenant
Tribal Protection
Tribal social worker
Unassigned
Utility representative
Veterans Services Staff
Visitor
Resource Type:
-- Please Select --
Caretaker
Conservator
Durable Power of Attorney
Legal guardian and/or estate
Legal guardian of the estate
Legal guardian of the person
Mandated Reporter
Mental Health Provider
Next of kin
No known legal relationship
Non-Mandated Reporter
Not Assigned
Other
Power of attorney
Representative payee
Self
Trustee
Unassigned
Relation to Victim:
-- Please Select --
Aunt
Brother
Cousin
Daughter
Ex-spouse
Father
Granddaughter
Grandparent
Grandson
Husband
In-law
Medical Staff
Minor Child
Mother
Nephew
Niece
None
Not Assigned
Other family
Partner or Domestic Partner
Self
Significant Other
Sister
Son
Spouse
Step-parent
Stepchild
Uncle
Unknown
Wife
Email:
Work Place:
Occupation:
Address:
Lives with client
City:
State:
-- Please Select --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip Code:
-
Primary Phone:
-- Please Select --
Home Phone
Work Phone
Cell/Other Phone
Home Phone:
Work Phone:
Other Phone:
Best time of day to reach you (25 chars max):
Incident Information
Date of incident:
Time of incident:
12 AM
1 AM
2 AM
3 AM
4 AM
5 AM
6 AM
7 AM
8 AM
9 AM
10 AM
11 AM
12 PM
1 PM
2 PM
3 PM
4 PM
5 PM
6 PM
7 PM
8 PM
9 PM
10 PM
11 PM
:
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
*
Address:
Use client address
Phone
City:
Zip Code:
-
Incident Occurred At:
-- Please Select --
Financial Institution
Home/Apt of Others
Hospital/Acute Care Hospital
Other
Own Home
Skilled Nursing Facility
Incident Other:
Select the institution reporting (if applicable):
-- Please Select --
Bank of America
Other
Wells Fargo
Situation Reported
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?
Yes
No
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.)
Yes
No
If yes please specify: (500 characters max)
Targeted Account
Targeted Account Number (Last 4 Digits):
Type of Account:
Credit
Deposit
Other
Trust Account:
Yes
No
Power of Attorney:
Yes
No
Direct Deposit:
Yes
No
Other Accounts:
Yes
No
Other Persons Believed To Have Knowledge Of Abuse Family Member Or Other Person Responsible For Victim's Care. (If unknown, list contact person)
Add Person
First Name:
Last Name:
DOB:
SSN:
###-##-####
Gender:
-- Please Select --
Female
Male
Not Assigned
Not Listed
Trans-Man
Trans-Woman
Unknown
Race:
-- Please Select --
Black or African-American
Cambodian
Chinese
Filipino
Guamanian or Chamorro
Hawaiian
Hispanic
Japanese
Korean
Loatian
Native American
Native Hawaiian or Other Pacific Islander
Not Assigned
Other
Other Asian
Samoan
Vietnamese
White
Collateral Type:
-- Please Select --
211 Helpline
988 Suicide/Crisis Line
Administrator/owner/operator
Adult Day Care Provider/Staff
Anonymous
Apartment Manager
APS Worker
Area Agency on Aging
Assisted Living Facility
Attorney
Bank Manager
Bank or Credit Union Staff
Board & Care Home Provider/Staff
Brokerage employee
Caregiver
Case Mgr
Child Protective Services (CPS)
Chiropractor
Clergy
Client
Community Center Staff
Consumer Protection
Contact Person Only
Counselor or therapist
Dental Provider or staff
Direct care staff
Discharge planner/hospital
District Attorney
Domestic violence center
Eligibility SW or Staff
EMT or Rescue Personnel
ER Staff/Doctor/Nurse
Family
Fiduciary
Financial Institution
Financial Manager employee
Financial Services Provider, other
Firefighter/Fire Department Other
First responder
Former care provider
Friend/Neighbor
Guardian
Health Provider
Home Delivered Meals staff
Home health provider/staff
Hospice provider
Hospital
Housing Code Enforcement Staff
IHSS SW/Staff
Insurance Provider or Staff
Judge
Landlord or Employee of Client Residence
Law and Code Enforcement/Legal Provider
Law enforcement
Licensed practical nurse
Meal Provider
Medical Clinic Provider
Medical examiner
Medical Technician
Medical Transportation
Mental health professional
Money Manager
MRT
Neighbor
Not Assigned
Nurse
Nurse aid
Nursing home staff
Occupational or Physical Therapist
Ombudsman
Other
Other Code Enforcement Staff
Other County/State Program staff
Other Organization Staff
Paid caregiver
Paramedic
Pharmacist
Physician
Physician Assistant
Probate Court
Public Authority/Staff
Public Education Staff
Public Guardian/Administrator
Public transportation driver
Regional Center Provider
Religious adviser or religious staff
Repair person
Retail
Roommate/Housemate
Sales
Self
Service Coordinator
Social Service Provider
Social worker/social services staff
Sr Service Agency Provider
State agency employee
Telemarketer
Tenant
Tribal Protection
Tribal social worker
Unassigned
Utility representative
Veterans Services Staff
Visitor
Resource Type:
-- Please Select --
Caretaker
Conservator
Durable Power of Attorney
Legal guardian and/or estate
Legal guardian of the estate
Legal guardian of the person
Mandated Reporter
Mental Health Provider
Next of kin
No known legal relationship
Non-Mandated Reporter
Not Assigned
Other
Power of attorney
Representative payee
Self
Trustee
Unassigned
Relation to Victim:
-- Please Select --
Aunt
Brother
Cousin
Daughter
Ex-spouse
Father
Granddaughter
Grandparent
Grandson
Husband
In-law
Medical Staff
Minor Child
Mother
Nephew
Niece
None
Not Assigned
Other family
Partner or Domestic Partner
Self
Significant Other
Sister
Son
Spouse
Step-parent
Stepchild
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