Adult Protective Services

Note: Any fields with * are required

VICTIM

First Name:

Middle Name:

*Last Name:

* Please enter Age or Date of Birth:

Age (or approx. age):

Exact Age Unknown

DOB:

SSN:

Language:

Speaks English:

Race:

Ethnicity:

Gender:

Sexual Orientation:

Living Arrangements:

Address:

City:

Zip Code:

Primary Phone:

Home Phone:

Work Phone:

ext:

Cell/Other:

Current Location: (if different from address)

Physical/Mental Impairments (if under 65):

SUSPECTED ABUSER #1

First Name:

*Last Name:

Age:

DOB:

SSN:

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:

Work Phone:

ext:

Cell/Other:

SUSPECTED ABUSER #2

First Name:

Last Name:

Age:

DOB:

SSN:

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:

Work Phone:

ext:

Cell/Other:

SUSPECTED ABUSER #3

First Name:

Last Name:

Age:

DOB:

SSN:

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:

Work Phone:

ext:

Cell/Other:

REPORTING PARTY

*First Name:

*Last Name:

Gender:

Ethnicity:

Race:

*Collateral Type:

Resource Type:

*Relation to AV:

*Email:

*Work Place:

*Occupation:

*Address Line 1:

Lives with client

Address Line 2:

City:

State:

Zip Code:

Primary Phone:

Home Phone:

Work Phone:

ext:

Cell/Other:

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

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:

Incident Occurred At: Incident Other:

Select the institution reporting (if applicable):

Facility:

REPORTED TYPES OF ABUSE (check all that apply)

If Other, please specify:

Self Neglect Allegations: Self Neglect

If Other, please specify:

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?

Access to alleged victim options YesNo

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 there basic daily needs? Are they wheel chair 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 YesNo

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:

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:

Work Phone:

ext:

Cell/Other:

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.

^ Back to top