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Incident Information
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Client Information
*
First Name:
Middle Name:
*
Last Name:
*
DOB:
OR
Age:
Exact Age Unknown
SSN:
###-##-####
Language:
-- Please Select --
Arabic
Armenian
Assistive technology
Cambodian
Cantonese
Chinese
English
Farsi
French
German
Hebrew
Hmong
Investigator Requested/Not Provided
Italian
Japanese
Korean
Lao
Llacano
Mandarin
Mien
Not Assigned
Other Chinese
Other non-English
Polish
Portuguese
Refused
Russian
Samoan
Sign Language American
Sign Language Other
Spanish
Tagalog
Thai
Tongan
Turkish
Unknown
Vietnamese
Speaks English
Veteran Status:
-- Please Select --
Investigator Requested/Not Provided
Non-Veteran
Not Assigned
Refused
Unknown
Veteran
Race:
-- Please Select --
American Indian or Alaskan Native
Asian (non-specific)
Asian Indian
Black or African-American
Cambodian
Chinese
Filipino
Guamanian or Chamorro
Hawaiian
Hispanic
Investigator Requested/Not Provided
Japanese
Korean
Loatian
Native American
Native Hawaiian or Other Pacific Islander
Not Assigned
Other Asian
Refused
Samoan
Tongan
Unknown
Vietnamese
White
Ethnicity:
-- Please Select --
Hispanic or Latino/a or Spanish Origin
Investigator Requested/Not Provided
Mexican, Mexican American or Chicano/a
Native American
Not Assigned
Not Hispanic, Latino/a or Spanish Origin
Other Hispanic or Spanish Origin
Puerto Rican
Refused
Unknown
Gender:
-- Please Select --
Female
Investigator Requested/Not Provided
Male
Not Assigned
Not Listed
Refused
Trans-Man
Trans-Woman
Unknown
Gender Other:
Sexual Orientation:
-- Please Select --
Bisexual
Gay/Lesbian
Investigator Requested/Not Provided
Not Assigned
Other
Refused
Straight
Unknown
S.O. Other:
Living Arrangements:
-- Please Select --
Assisted Living Facility
Group Home
Home of others
Homeless
Hotel
ICFID
Investigator Requested/Not Provided
Other
Own Home - Lives Alone
Own Home - Others living in the home
Refused
Room and Board
Skilled Nursing Facility
Unknown
Martial Status:
-- Please Select --
Domestic Partnership
Investigator Requested/Not Provided
Married
Not Assigned
Refused
Separated
Single
Unknown
Widowed
Home Phone :
Work Phone :
Cell/Other Phone:
Address:
City:
Zip Code:
Current Location: (if different from address)
Physical/Mental Impairments (if under 65):
Reported Types Of Abuse (Check All That Apply)
*Required
Abuse Resulted In:
01. Abandonment
02. Emotional Distress
03. Isolation
04. Fear
05. Lack of required care
06. Financial loss
07. Physical Pain
08. Minor Medical Care
09. Physical Injury
10. Hospitalization
11. Death
12. Unknown
Other
If Other, please specify:
Self Neglect Allegations:
Please select at least one Self Neglect or Abuse Perpetrated by Others Allegation
Self Neglect
If Other, please specify:
Abuse Perpetrated by Others:
Please select at least one Self Neglect or Abuse Perpetrated by Others Allegation
Sexual Abuse
Isolation
Financial Exploitation
Caretaker Neglect
Emotional Abuse
Sexual Exploitation
Unlawful Restraint
Criminal Activity / Exploitation
Deprivation of Treatment
Physical Injury/Harm
Personal Dignity Exploitation
Endangerment
If Other, please specify:
Suspected Abuser #1
First Name:
*
Last Name:
SSN:
Gender:
-- Please Select --
Female
Investigator Requested/Not Provided
Male
Not Assigned
Not Listed
Refused
Trans-Man
Trans-Woman
Unknown
Collateral Type:
-- Please Select --
APS Caseworker
Area Agency on Aging
Assisted Living Facility Staff
Attorney
Auditor
Bank or Credit Union Staff
Clergy
Code Enforcement Personnel
Corrections or probation employee
Court Personnel
DSPD Provider
DSPD State Employee
Education / School Personnel
Emergency Services Personnel
Facility Resident
Financial Services Personnel
Friend
Guardianship or Conservatorship (non-specific)
Health care proxy in effect
Home Health Services Personnel
Investigator Requested/Not Provided
Landlord
Law enforcement
Long-Term Care Ombudsman
Medicaid Fraud Control Unit (MFCU)
Medical / Dental Personnel
Mental / Behavior health Personnel
Neighbor
No role identified / Anonymous:
Not Assigned
Nursing home staff
Other
Public Service Case Manager
Public transportation driver
Refused
Relative
Self
Unknown
USDC Personnel
Utah State Hospital Personnel
Volunteer services provider
Resource Type:
-- Please Select --
Caretaker
Financial Proxy
Health Care Proxy
Investigator Requested/Not Provided
Legal guardian of person and estate
Legal guardian of the estate
Legal guardian of the person
Next of kin
No known legal relationship
Not Assigned
Power of attorney
Refused
Representative Payee
Unknown
Relation to Victim:
-- Please Select --
Aunt
Brother
Child
Cousin
Daughter
Domestic partner, including civil union
Father
Granddaughter
Grandfather
Grandmother
Grandson
Husband
In-law
Investigator Requested/Not Provided
Mother
Nephew
Niece
None
Not Assigned
Other relative
Parent
Refused
Self
Sister
Son
Spouse
Stepdaughter
Stepfather
Stepmother
Stepson
Unknown
Home Phone :
Work Phone :
Cell/Other Phone:
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:
-
DOB:
OR
Age:
Ethnicity:
-- Please Select --
Hispanic or Latino/a or Spanish Origin
Investigator Requested/Not Provided
Mexican, Mexican American or Chicano/a
Native American
Not Assigned
Not Hispanic, Latino/a or Spanish Origin
Other Hispanic or Spanish Origin
Puerto Rican
Refused
Unknown
Race:
-- Please Select --
American Indian or Alaskan Native
Asian (non-specific)
Asian Indian
Black or African-American
Cambodian
Chinese
Filipino
Guamanian or Chamorro
Hawaiian
Hispanic
Investigator Requested/Not Provided
Japanese
Korean
Loatian
Native American
Native Hawaiian or Other Pacific Islander
Not Assigned
Other Asian
Refused
Samoan
Tongan
Unknown
Vietnamese
White
Eyes:
Hair:
Weight:
Height:
Suspected Abuser # 2
First Name:
*Last Name:
SSN:
Gender:
-- Please Select --
Female
Investigator Requested/Not Provided
Male
Not Assigned
Not Listed
Refused
Trans-Man
Trans-Woman
Unknown
Collateral Type:
-- Please Select --
APS Caseworker
Area Agency on Aging
Assisted Living Facility Staff
Attorney
Auditor
Bank or Credit Union Staff
Clergy
Code Enforcement Personnel
Corrections or probation employee
Court Personnel
DSPD Provider
DSPD State Employee
Education / School Personnel
Emergency Services Personnel
Facility Resident
Financial Services Personnel
Friend
Guardianship or Conservatorship (non-specific)
Health care proxy in effect
Home Health Services Personnel
Investigator Requested/Not Provided
Landlord
Law enforcement
Long-Term Care Ombudsman
Medicaid Fraud Control Unit (MFCU)
Medical / Dental Personnel
Mental / Behavior health Personnel
Neighbor
No role identified / Anonymous:
Not Assigned
Nursing home staff
Other
Public Service Case Manager
Public transportation driver
Refused
Relative
Self
Unknown
USDC Personnel
Utah State Hospital Personnel
Volunteer services provider
Resource Type:
-- Please Select --
Caretaker
Financial Proxy
Health Care Proxy
Investigator Requested/Not Provided
Legal guardian of person and estate
Legal guardian of the estate
Legal guardian of the person
Next of kin
No known legal relationship
Not Assigned
Power of attorney
Refused
Representative Payee
Unknown
Relation to Victim:
-- Please Select --
Aunt
Brother
Child
Cousin
Daughter
Domestic partner, including civil union
Father
Granddaughter
Grandfather
Grandmother
Grandson
Husband
In-law
Investigator Requested/Not Provided
Mother
Nephew
Niece
None
Not Assigned
Other relative
Parent
Refused
Self
Sister
Son
Spouse
Stepdaughter
Stepfather
Stepmother
Stepson
Unknown
Home Phone:
Work Phone :
Cell/Other Phone:
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:
-
DOB:
OR
Age:
Ethnicity:
-- Please Select --
Hispanic or Latino/a or Spanish Origin
Investigator Requested/Not Provided
Mexican, Mexican American or Chicano/a
Native American
Not Assigned
Not Hispanic, Latino/a or Spanish Origin
Other Hispanic or Spanish Origin
Puerto Rican
Refused
Unknown
Race:
-- Please Select --
American Indian or Alaskan Native
Asian (non-specific)
Asian Indian
Black or African-American
Cambodian
Chinese
Filipino
Guamanian or Chamorro
Hawaiian
Hispanic
Investigator Requested/Not Provided
Japanese
Korean
Loatian
Native American
Native Hawaiian or Other Pacific Islander
Not Assigned
Other Asian
Refused
Samoan
Tongan
Unknown
Vietnamese
White
Eyes:
Hair:
Weight:
Height:
-
Suspected Abuser # 3
First Name:
*Last Name:
SSN:
Gender:
-- Please Select --
Female
Investigator Requested/Not Provided
Male
Not Assigned
Not Listed
Refused
Trans-Man
Trans-Woman
Unknown
Collateral Type:
-- Please Select --
APS Caseworker
Area Agency on Aging
Assisted Living Facility Staff
Attorney
Auditor
Bank or Credit Union Staff
Clergy
Code Enforcement Personnel
Corrections or probation employee
Court Personnel
DSPD Provider
DSPD State Employee
Education / School Personnel
Emergency Services Personnel
Facility Resident
Financial Services Personnel
Friend
Guardianship or Conservatorship (non-specific)
Health care proxy in effect
Home Health Services Personnel
Investigator Requested/Not Provided
Landlord
Law enforcement
Long-Term Care Ombudsman
Medicaid Fraud Control Unit (MFCU)
Medical / Dental Personnel
Mental / Behavior health Personnel
Neighbor
No role identified / Anonymous:
Not Assigned
Nursing home staff
Other
Public Service Case Manager
Public transportation driver
Refused
Relative
Self
Unknown
USDC Personnel
Utah State Hospital Personnel
Volunteer services provider
Resource Type:
-- Please Select --
Caretaker
Financial Proxy
Health Care Proxy
Investigator Requested/Not Provided
Legal guardian of person and estate
Legal guardian of the estate
Legal guardian of the person
Next of kin
No known legal relationship
Not Assigned
Power of attorney
Refused
Representative Payee
Unknown
Relation to Victim:
-- Please Select --
Aunt
Brother
Child
Cousin
Daughter
Domestic partner, including civil union
Father
Granddaughter
Grandfather
Grandmother
Grandson
Husband
In-law
Investigator Requested/Not Provided
Mother
Nephew
Niece
None
Not Assigned
Other relative
Parent
Refused
Self
Sister
Son
Spouse
Stepdaughter
Stepfather
Stepmother
Stepson
Unknown
Home Phone:
Work Phone:
Cell/Other Phone:
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:
-
DOB:
OR
Age:
Ethnicity:
-- Please Select --
Hispanic or Latino/a or Spanish Origin
Investigator Requested/Not Provided
Mexican, Mexican American or Chicano/a
Native American
Not Assigned
Not Hispanic, Latino/a or Spanish Origin
Other Hispanic or Spanish Origin
Puerto Rican
Refused
Unknown
Race:
-- Please Select --
American Indian or Alaskan Native
Asian (non-specific)
Asian Indian
Black or African-American
Cambodian
Chinese
Filipino
Guamanian or Chamorro
Hawaiian
Hispanic
Investigator Requested/Not Provided
Japanese
Korean
Loatian
Native American
Native Hawaiian or Other Pacific Islander
Not Assigned
Other Asian
Refused
Samoan
Tongan
Unknown
Vietnamese
White
Eyes:
Hair:
Weight:
Height:
-
+ Add Another
Reporting Party
*
First Name:
*
Last Name:
Gender:
-- Please Select --
Female
Investigator Requested/Not Provided
Male
Not Assigned
Not Listed
Refused
Trans-Man
Trans-Woman
Unknown
Ethnicity:
-- Please Select --
Hispanic or Latino/a or Spanish Origin
Investigator Requested/Not Provided
Mexican, Mexican American or Chicano/a
Native American
Not Assigned
Not Hispanic, Latino/a or Spanish Origin
Other Hispanic or Spanish Origin
Puerto Rican
Refused
Unknown
Race:
-- Please Select --
American Indian or Alaskan Native
Asian (non-specific)
Asian Indian
Black or African-American
Cambodian
Chinese
Filipino
Guamanian or Chamorro
Hawaiian
Hispanic
Investigator Requested/Not Provided
Japanese
Korean
Loatian
Native American
Native Hawaiian or Other Pacific Islander
Not Assigned
Other Asian
Refused
Samoan
Tongan
Unknown
Vietnamese
White
*
Collateral Type:
-- Please Select --
APS Caseworker
Area Agency on Aging
Assisted Living Facility Staff
Attorney
Auditor
Bank or Credit Union Staff
Clergy
Code Enforcement Personnel
Corrections or probation employee
Court Personnel
DSPD Provider
DSPD State Employee
Education / School Personnel
Emergency Services Personnel
Facility Resident
Financial Services Personnel
Friend
Guardianship or Conservatorship (non-specific)
Health care proxy in effect
Home Health Services Personnel
Investigator Requested/Not Provided
Landlord
Law enforcement
Long-Term Care Ombudsman
Medicaid Fraud Control Unit (MFCU)
Medical / Dental Personnel
Mental / Behavior health Personnel
Neighbor
No role identified / Anonymous:
Not Assigned
Nursing home staff
Other
Public Service Case Manager
Public transportation driver
Refused
Relative
Self
Unknown
USDC Personnel
Utah State Hospital Personnel
Volunteer services provider
Resource Type:
-- Please Select --
Caretaker
Financial Proxy
Health Care Proxy
Investigator Requested/Not Provided
Legal guardian of person and estate
Legal guardian of the estate
Legal guardian of the person
Next of kin
No known legal relationship
Not Assigned
Power of attorney
Refused
Representative Payee
Unknown
Relation to Victim:
-- Please Select --
Aunt
Brother
Child
Cousin
Daughter
Domestic partner, including civil union
Father
Granddaughter
Grandfather
Grandmother
Grandson
Husband
In-law
Investigator Requested/Not Provided
Mother
Nephew
Niece
None
Not Assigned
Other relative
Parent
Refused
Self
Sister
Son
Spouse
Stepdaughter
Stepfather
Stepmother
Stepson
Unknown
*
Email:
*
Work Place:
*
Occupation:
Home Phone:
*
Work Phone:
Other Phone:
*
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:
-
Best time of day to reach you (25 chars max):
How did you hear about APS?:
-- Please Select --
APS Flyers/Brochures
APS led Training/Presentation
Division of Aging and Adult Services website
Friend/Neighbor/Family Member
Mandatory Reporter
My workplace provided APS training
Not Listed
Not Provided
Online Search
Prior Contact with APS
Referred (e.g., law enforcement, AAA, DHHS, etc.)
Social Media
TV/Radio
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 --
Adult Day Service Center Non Specific
Assisted Living Facility
Home/Apt of Others
Hospital/Acute Care Hospital
ICFID
Investigator Requested/Not Provided
Investigator Requested/Not Provided
On the Street / Homeless
Other
Own Home
Refused
Residential Care
Skilled Nursing Facility
Unknown
Utah State Developmental Center
Work / School
Incident Other:
Select the institution reporting (if applicable):
-- Please Select --
NeuroRestorative Live Care Center
ABBINGTON MANOR AL I
ABBINGTON MANOR AL II
ABBINGTON MANOR MEMORY CARE
ADVANCED CARE OF ST. GEORGE
ADVANCED HEALTH CARE OF SALEM
ALL SEASONS OF CEDAR CITY
ALL SEASONS OF WEST JORDAN #3
ALL SEASONS SALT LAKE
ALPINE MEADOW REHABILITATION AND NURSING
ALTA RIDGE - HOLLADAY
ALTA RIDGE - SANDY AL
ALTA RIDGE-SANDY MC
ANTHOLOGY OF SOUTH JORDAN
APPLE TREE ASSISTED LIVING
APPLE VILLAGE ASSISTED LIVING
ASHFORD ASSISTED LIVING & MEMORY CARE OF SPRINGVIL
ASPEN ASSISTED LIVING LLC
ASPEN PARK REHABILITATION
ASPEN RIDGE OF UTAH VALLEY
ASPEN RIDGE TRANSITIONAL REHAB
ASPEN RIDGE WEST TRANSITIONAL REHAB
Assisted Living Facility
ASSISTED LIVING OF DRAPER
ASSISTED LIVING OF DRAPER
ASSISTED LIVING OF OREM NORTH VILLA
ASSISTED LIVING OF OREM SOUTH VILLA
AUTUMN CARE 2 LIVING CENTER
AUTUMN CARE LIVING CENTER
AUTUMN PARK
AUTUMN PARK ASSISTED LIVING LLC
AVALON CARE CENTER-BOUNTIFUL
AVALON VALLEY REHABILITATION
AVALON WEST HEALTH & REHABILITATION
AVAMERE AT MOUNTAIN RIDGE
BARRINGTON PLACE ALZHEIMER'S SPECIAL CARE CENTER
BEACON CREST MANAGEMENT OF DRAPER LLC
BEACON HEIGHTS SENIOR LIVING; LLC
BEEHIVE AT EAST MILLCREEK
BEEHIVE HOME SANTAQUIN
BEEHIVE HOMES OF AMERICAN FORK SOUTH BUILDING TWO
BEEHIVE HOMES OF AMERICAN FORK SOUTH; BUILDING ONE
BEEHIVE HOMES OF CEDAR CITY #1
BEEHIVE HOMES OF CEDAR CITY #2
BEEHIVE HOMES OF CEDAR CITY #3
BEEHIVE HOMES OF DRAPER
BEEHIVE HOMES OF DRAPER; 2
BEEHIVE HOMES OF ELMO
BEEHIVE HOMES OF HERRIMAN
BEEHIVE HOMES OF KANAB
BEEHIVE HOMES OF LAYTON
BEEHIVE HOMES OF LEHI
BEEHIVE HOMES OF LOA
BEEHIVE HOMES OF LOGAN
BEEHIVE HOMES OF MAESER
BEEHIVE HOMES OF MAGNA
BEEHIVE HOMES OF NAPLES
BEEHIVE HOMES OF OREM
BEEHIVE HOMES OF OREM #1
BEEHIVE HOMES OF OREM #2
BEEHIVE HOMES OF PARK CITY
BEEHIVE HOMES OF PAYSON
BEEHIVE HOMES OF PERRY
BEEHIVE HOMES OF PRICE
BEEHIVE HOMES OF PROVO
BEEHIVE HOMES OF PROVO #2
BEEHIVE HOMES OF RICHFIELD #1
BEEHIVE HOMES OF RICHFIELD #2
BEEHIVE HOMES OF RIVERTON
BEEHIVE HOMES OF SALEM
BEEHIVE HOMES OF SALEM II
BEEHIVE HOMES OF SALT LAKE
BEEHIVE HOMES OF SPANISH FORK
BEEHIVE HOMES OF ST GEORGE #1
BEEHIVE HOMES OF ST GEORGE #2
BEEHIVE HOMES OF SYRACUSE
BEEHIVE HOMES OF TOOELE
BEEHIVE HOMES OF VERNAL
BEEHIVE HOMES OF WASHINGTON COUNTY #3
BEEHIVE HOMES OF WASHINGTON COUNTY #5
BEEHIVE HOMES OF WASHINGTON COUNTY #6
BEEHIVE HOMES OF WASHINGTON COUNTY #7
BEEHIVE HOMES OF WASHINGTON COUNTY #8
BEEHIVE HOMES OF WASHINGTON COUNTY IV
BEEHIVE HOMES OF WASHINGTON COUNTY#9
BEEHIVE HOMES OF WEST JORDAN #2
BEEHIVE HOMES OF WEST JORDAN #3
BEEHIVE HOMES OF WEST JORDAN; #1
BEEHIVE STONEY BROOKE; INC
BEEHIVES HOMES OF SOUTH JORDAN
BEL AIRE HOMES
BEL AIRE SENIOR LIVING
BELLA TERRA CEDAR CITY
BELLA TERRA ST GEORGE
BELLAVIEW ASSISTED LIVING AND MEMOPRY CARE
BEST ASSISTED LIVING OF BELL CANYON
BEST ASSISTED LIVING, LLC
BIRCH CREEK ASSISTED LIVING
BLACKSMITH FORK ASSISTED LIVING
BLUFF POINT CARE
BRIGHTON HOUSE OF RIVERTON
BRIGHTON HOUSE OF SOUTH JORDAN
BRIGHTWORK VILLA AMERICAN FORK
BRIGHTWORK VILLA PARK PLACE
BRIGHTWORK VILLA PLEASANT GROVE
BROOKDALE CEDAR CITY
BROOKDALE NORTH OGDEN
BROOKDALE SALT LAKE CITY AL
BROOKDALE SALT LAKE CITY SNF
BUNGALOW CARE CENTER
CACHE VALLEY ASSISTED LIVING
CANTERBURY ASSISTED LIVING
CANTERBURY ASSISTED LIVING (WEST)
CANYON BREEZE SENIOR LIVING
CANYON COVE ASSISTED LIVING
CANYON CREEK ASSISTED LIVING
CANYON RIM CARE CENTER
CANYONLANDS CARE CENTER
CAPITOL HILL SENIOR LIVING
CARESOURCE REHAB AND SUPPORTIVE CARE
CARRINGTON COURT
CASCADES AT ORCHARD PARK
CASCADES AT RIVERWALK
CEDAR HEALTH AND HOSPICE
CEDARWOOD AT SANDY ASSISTED LIVING
CHANCELLOR GARDENS OF CLEARFIELD
CITY CREEK POST ACUTE
CLEARFIELD STONEY BROOKE
COPPER RIDGE HEALTH CARE
CORAL DESERT REHABILITATION AND CARE
COTTAGE GLEN
COTTONWOOD CREEK
COTTONWOOD CREEK II
COTTONWOOD PLACE
COUNTRY CARE
COUNTRY CARE II
COUNTRY HOME ASSISTED LIVING INC
COUNTRY LANE ACQUISITION; LLC I
COUNTRY LANE ACQUISITION; LLC II
COUNTRY LANE MOUNT PLEASANT LLC
COUNTRY LANE OF CENTRAL SANDY
COUNTRY LANE OF EAST SANDY
COUNTRY LANE OF OGDEN
COUNTRY LANE OF SANTAQUIN
COUNTRY LANE OF WEST SANDY
COUNTRY LANE PAYSON
COUNTRY LIFE CARE CENTER
COUNTRY OAKS ASSISTED LIVING OF BOUNTIFUL
COUNTRY OAKS ASSISTED LIVING OF LAYTON
COUNTRY PINES RETIREMENT HOME
COUNTRY VIEW ASSISTED LIVING
COURTYARD AT JAMESTOWN ASSISTED LIVING COMMUNITY
COVE POINT RETIREMENT
COVINGTON SENIOR LIVING
CREEKSIDE SENIOR LIVING
CRESTWOOD REHABILITATION AND NURSING
DIAMOND D INN
DIAMOND JANE'S ASSISTED LIVING
DRAPER REHABILITATION AND CARE CENTER
EAST SIDE CENTER
EDITH PORTER RN HOME CARE
ELDERBERRY CARE
ELK MEADOWS ASSISTED LIVING AND MEMORY CARE
ELK RIDGE ASSISTED LIVING
EMERY COUNTY CARE AND REHABILITATION CENTER
EVERGREEN RESIDENTIAL CARE
FAIRFIELD VILLAGE OF LAYTON
FAIRFIELD VILLAGE REHABILITATION
FAIRVIEW CARE CENTER EAST
FAMILY TREE OF MORGAN
FAMILY TREE OF WEST POINT
FOUR CORNERS REGIONAL CARE CENTER
GABLES OF BRIGHAM CITY
GABLES OF NORTH LOGAN ASSISTED LIVING
GARDENS ASSISTED LIVING
GARFIELD COUNTY NURSING HOME
GEORGE E WAHLEN OGDEN VETERANS HOME
GOLDEN LIVING TAYLORSVILLE
GOLDEN SKYLINE ASSISTED LIVING
GOLDEN SKYLINE ASSISTED LIVING #2
GOOD LIFE SENIOR LIVING
GREEN GABLES
GROVE CREEK SENIOR LIVING
HARMONY HILLS OF LEHI
HARRISON POINTE HEALTHCARE AND REHABILITATION
HEART & HOME ASSISTED LIVING
HEARTHSTONE MANOR ASSISTED LIVING
HEIRLOOM INN
HERITAGE CARE CENTER
HERITAGE HAVEN
HERITAGE HILLS REHABILITATION AND CARE CENTER
HERITAGE HOME
HERITAGE PARK HEALTHCARE AND REHABILITATION
HERITAGE PLACE
HERITAGE SENIOR COMMUNITIES
HIDDEN HOLLOW CARE CENTER
HIDDEN VALLEY ASSISTED LIVING; LLC
HIGHLAND CARE CENTER
HIGHLAND COVE RETIREMENT COMMUNITY
HIGHLAND GLEN
HILLCREST CARE CENTER
HOLLADAY HEALTHCARE CENTER
HOLLADAY HOME FOR THE ELDERLY
HURRICANE HEALTH AND REHABILITATION
ICFID
IRON COUNTY CARE CENTER; LLC
IRON COUNTY NURSING HOME
J AND E HOME CARE
JEWELS LEGACY GARDEN
LAKE RIDGE SENIOR LIVING - NORTH
LAKE RIDGE SENIOR LIVING - SOUTH
LAKEVIEW ELDERLY CARE
LAUREL GROVES ASSISTED LIVING CENTER
LAYTON PARK MEMORY CARE; LLC
LEGACY HOUSE ASSISTED LIVING OF SOUTH JORDAN
LEGACY HOUSE OF BOUNTIFUL
LEGACY HOUSE OF LOGAN ASSISTED LIVING
LEGACY HOUSE OF OGDEN
LEGACY HOUSE OF SPANISH FORK
LEGACY HOUSE OF TAYLORSVILLE
LEGACY VILLAGE MEMORY CARE
LEGACY VILLAGE OF PROVO
LEGACY VILLAGE OF SUGAR HOUSE
LEGACY VILLAGE REHABILITATION
LIFE CARE CENTER OF BOUNTIFUL
LIFE CARE CENTER OF SALT LAKE CITY
LINDON CARE AND TRAINING CENTER
LITTLE COTTONWOOD REHABILITATION AND NURSING; LLC
LOGAN REGIONAL HOSPITAL TRANSITIONAL CARE UNIT
LOMOND PEAK NURSING AND REHABILITATION; LLC
LOTUS PARK ASSISTED LIVING & MEMORY CARE BLDG 5
LOTUS PARK ASSISTED LIVING & MEMORY CARE BLDG 6
LOTUS PARK ASSISTED LIVING LLC
LOTUS PARK CARE CENTERS
MANILA HILLS HOME
MAPLE MOUNTAIN ASSISTED LIVING
MAPLE RIDGE REHABILITATION AND NURSING
MAPLE SPRINGS
MAPLE SPRINGS OF NORTH LOGAN
MAPLE SPRINGS SENIOR LIVING
MEADOW BROOK REHABILITATION AND NURSING
MEDALLION MANOR
MEDALLION SUPPORTED LIVING
MEDALLION SUPPORTED LIVING - PAYSON
MEDALLION SUPPORTED LIVING-SPRINGVILLE
Medical Facility
MEMORY LANE CARE HOME
MERVYN SHARP BENNION CENTRAL UTAH VETERANS HOME - PAYSON
MESA VISTA; INC
MICHELLE'S RETREAT
MIDTOWN MANOR
MILLARD COUNTY CARE AND REHABILITATION
MILLCREEK REHABILITATION AND NURSING; LLC
MISSION AT ALPINE REHABILITATION CENTER
MISSION AT BEAR RIVER REHABILITATION CENTER
MISSION AT COMMUNITY ASSISTED LIVING
MISSION AT COMMUNITY LIVING REHABILITATION CENTER
MISSION AT HILLSIDE REHABILITATION CENTER
MISSION AT MAPLE SPRINGS
MONROE CANYON ASSISTED LIVING
MOUNTAIN RIDGE ASSISTED LIVING
MOUNTAIN VIEW HEALTH SERVICES
MT OGDEN HEALTH AND REHABILITATION CENTER
MT OLYMPUS REHABILITATION CENTER
NEURORESTORATIVE
NIITSUMA LIVING CENTER
NORTH CANYON CARE CENTER
NORTH SIDE CENTER
Nursing Home
OAK RIDGE ASSISTED LIVING
OREM REHABILITATION AND NURSING CENTER
OSMOND SENIOR LIVING IN LINDON
OSMOND SENIOR LIVING IN LINDON AL2
OSMOND SENIOR LIVING MEMORY CARE IN SALT LAKE
Other
OUR HOUSE OF OGDEN
OUR HOUSE OF TREMONTON
OUR HOUSE OF TREMONTON
PACIFICA SENIOR LIVING MILLCREEK AL I
PACIFICA SENIOR LIVING MILLCREEK AL II
PARAMOUNT HEALTH AND REHABILITATION
PARKDALE HEALTH AND REHAB
PARKSIDE MANOR
PARKWAY HEALTH CENTER
PEACHTREE PLACE
PHEASANT RUN ALZHEIMER'S SPECIAL CARE CENTER
PHEASANT VIEW ASSISTED LIVING; LLC
PINE CREEK REHABILITATION AND NURSING
PINE VIEW TRANSITIONAL REHAB
PINNACLE NURSING AND REHABILITATION CENTER
PIONEER CARE CENTER
PLATINUM CARE ASSISTED LIVING
POINTE MEADOWS HEALTH AND REHABILITATION
PROVO ASSISTED LIVING LLC
PROVO CARE CENTER
PROVO REHABILITATION AND NURSING
QUAIL MEADOW ASSISTED LIVING; LLC
RAINTREE SENIOR LIVING
REAL LIFE HOME CARE
RED CLIFFS ASSISTED LIVING
RED CLIFFS HEALTH AND REHAB
REID'S PARK PLACE
Residential Care
RICHFIELD REHABILITATION AND CARE CENTER
RIDGEVIEW GARDENS OF ST GEORGE
RIVER MEADOWS SENIOR LIVING
RIVERWAY ASSISTED LIVING AND MEMORY CARE
ROCKY MOUNTAIN CARE - CLEARFIELD
ROCKY MOUNTAIN CARE - COTTAGE ON VINE
ROCKY MOUNTAIN CARE - HUNTER HOLLOW
ROCKY MOUNTAIN CARE - LOGAN
ROCKY MOUNTAIN CARE - MOUNTAIN VIEW
ROCKY MOUNTAIN CARE - RIVERTON
Rocky Mountain Care - Spring Hollow
ROCKY MOUNTAIN CARE - WILLOW SPRINGS
Rocky Mountain Care- River Pointe Assisted Living
ROSECREST MANOR
ROSEWOOD ASSISTED CARE
ROY STONEY BROOKE
SAGEWOOD AT DAYBREAK
Sandstone American Fork
Sandstone Bountiful
Sandstone Brigham City
Sandstone Canyon Rim
Sandstone Holladay
Sandstone Millcreek
Sandstone Nephi
Sandstone North Park
Sandstone Pioneer Trail
Sandstone Richfield
Sandstone South Lake
Sandstone Taylorsville
SANDY HEALTH AND REHAB
SANTE ASSISTED LIVING HEBER
SARAH DAFT HOME
SEASONS ASSISTED LIVING OF FARR WEST
SEASONS HEALTH AND REHABILITATION
SEASONS OF SANTAQUIN
SEGO LILY ASSISTED LIVING
SOUTH DAVIS COMMUNITY CARE CENTER
SOUTH DAVIS SPECIALTY CARE
SOUTH OGDEN POST ACUTE
SOUTH VALLEY ASSISTED LIVING
SOUTHERN UTAH VETERANS HOME - IVINS
SPANISH FORK REHABILITATION AND NURSING
SPRING CREEK HEALTHCARE CENTER
SPRING GARDENS OF LINDON
SPRING GARDENS SENIOR LIVING
SPRING LANE
ST GEORGE REHABILITATION
ST JOSEPH VILLA
ST JOSEPH VILLA ASSISTED LIVING
ST MARK'S HOSPITAL TRANSITIONAL CARE
STERLING COURT
STONEHEDGE OF CEDAR CITY
STONEHENGE OF AMERICAN FORK
STONEHENGE OF OGDEN; LLC
STONEHENGE OF OREM
STONEHENGE OF RICHFIELD
STONEHENGE OF SOUTH JORDAN; LLC
STONEHENGE OF SPRINGVILLE; UT INC
STONEY BROOKE OF EDEN
SUMMERFIELD RETIREMENT LIVING INC
SUMMIT SENIOR LIVING
SUNRIDGE ASSISTED LIVING AND MEMORY CARE
SUNRISE AT HOLLADAY
SUNRISE OF SANDY
SUNRISE PARK ASSISTED LIVING
SUNSHINE TERRACE FOUNDATION
SUPERIOR ASSISTED LIVING
SUPERIOR ASSISTED LIVING OF BELL CANYON
SYRACUSE SUPPORTED LIVING
TERRACE GROVE ASSISTED LIVING
THATCHER BROOK REHABILITATION & CARE
THE ABBINGTON ASSISTED LIVING AND MEMORY CARE COMM
THE ABBINGTON AT HOLLADAY
THE ABBINGTON AT MAPLETON
THE AVENUES COURTYARD ASSISTED LIVING COMMUNITY
THE CHARLESTON AT CEDAR HILLS
THE COVENTRY ASSISTED LIVING
THE COVENTRY AT COTTONWOOD HEIGHTS I
THE COVENTRY AT COTTONWOOD HEIGHTS II
THE FAMILY PLACE SENIOR CENTER; LLC
THE INN ON BARTON CREEK
THE LODGE AT JORDAN RIVER
THE LODGE AT RIVERTON
THE MEADOWS I
THE MEADOWS II
THE MEADOWS III
THE PEAKS CARE AND REHAB
THE RETREAT AT SUNBROOK ASSISTED LIVING
THE RETREAT AT SUNRIVER ST GEORGE
THE RIDGE
THE TERRACE AT MT. OGDEN
THE VICTORIAN HOUSE
THE VILLAS AT BAER CREEK
THE WELLINGTON
THE WENTWORTH AT COVENTRY I SENIOR LIVING
THE WENTWORTH AT DRAPER
THE WENTWORTH AT EAST MILLCREEK
THE WENTWORTH AT THE MEADOWS I
THE WENTWORTH AT WILLOW CREEK
TOPHAMS TINY TOTS CARE CENTER
TRADITION ASSISTED LIVING
Truewood by Merrill
TRUEWOOD BY MERRILL, TAYLORSVILLE
UINTAH BASIN REHABILITATION AND SENIOR VILLA
UINTAH HEALTH CARE SPECIAL SERVICE DISTRICT
Utah State Developmental Center
UTAH STATE DEVELOPMENTAL CENTER
UTAH VALLEY HEALTHCARE AND REHABILITATION
Valencia at Cottonwood Heights
Valencia at Taylorsville
WAIKOLOA ASSISTED LIVNG
WASHINGTON TERRACE CENTER
WATERFALL ASSISTED LIVING
WELCOME HOME ASSISTED LIVING
WEST JORDAN CARE CENTER
WEST SIDE CENTER
WIDE HORIZONS RESIDENTIAL CARE FACILITY
WILLIAM E CHRISTOFFERSEN SALT LAKE VETERANS HOME
WILLIAMSBURG RETIREMENT COMMUNITY
WILLOW GLEN HEALTH AND REHAB
WILLOW WOOD CARE CENTER
WOODLAND PARK REHABILITATION AND CARE CENTER
Work/School
Situation Reported
Estimated loss to the victim (if financial):
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)
Please provide any other information that would help us investigate:
Target 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:
Gender:
-- Please Select --
Female
Investigator Requested/Not Provided
Male
Not Assigned
Not Listed
Refused
Trans-Man
Trans-Woman
Unknown
DOB
SSN
Invalid social security number. Example 1 2 3 - 4 5 - 6 7 8 9
###-##-####
Race
-- Please Select --
American Indian or Alaskan Native
Asian (non-specific)
Asian Indian
Black or African-American
Cambodian
Chinese
Filipino
Guamanian or Chamorro
Hawaiian
Hispanic
Investigator Requested/Not Provided
Japanese
Korean
Loatian
Native American
Native Hawaiian or Other Pacific Islander
Not Assigned
Other Asian
Refused
Samoan
Tongan
Unknown
Vietnamese
White
Collateral Type:
-- Please Select --
APS Caseworker
Area Agency on Aging
Assisted Living Facility Staff
Attorney
Auditor
Bank or Credit Union Staff
Clergy
Code Enforcement Personnel
Corrections or probation employee
Court Personnel
DSPD Provider
DSPD State Employee
Education / School Personnel
Emergency Services Personnel
Facility Resident
Financial Services Personnel
Friend
Guardianship or Conservatorship (non-specific)
Health care proxy in effect
Home Health Services Personnel
Investigator Requested/Not Provided
Landlord
Law enforcement
Long-Term Care Ombudsman
Medicaid Fraud Control Unit (MFCU)
Medical / Dental Personnel
Mental / Behavior health Personnel
Neighbor
No role identified / Anonymous:
Not Assigned
Nursing home staff
Other
Public Service Case Manager
Public transportation driver
Refused
Relative
Self
Unknown
USDC Personnel
Utah State Hospital Personnel
Volunteer services provider
Resource Type:
-- Please Select --
Caretaker
Financial Proxy
Health Care Proxy
Investigator Requested/Not Provided
Legal guardian of person and estate
Legal guardian of the estate
Legal guardian of the person
Next of kin
No known legal relationship
Not Assigned
Power of attorney
Refused
Representative Payee
Unknown
Relation to Victim:
-- Please Select --
Aunt
Brother
Child
Cousin
Daughter
Domestic partner, including civil union
Father
Granddaughter
Grandfather
Grandmother
Grandson
Husband
In-law
Investigator Requested/Not Provided
Mother
Nephew
Niece
None
Not Assigned
Other relative
Parent
Refused
Self
Sister
Son
Spouse
Stepdaughter
Stepfather
Stepmother
Stepson
Unknown
Email:
Work Place:
Occupation:
Home Phone:
Work Phone:
Cell/Other Phone:
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:
-
*
I understand that if I do not see a confirmation message my report has NOT been submitted and I must check for errors or incomplete entries on the form.
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