Note: Any fields with * are required

 VICTIM
 
    *
  *  OR      
        
        
    
    

  
    
      
    

  Address:
  
  Zip Code:  - 
   
  
  

Vulnerabilities:




 SUSPECTED ABUSER
 
     *
       
   Community relationship such as doctor, pharmacist, bank teller, etc    Legal relationship Family relationship
     
    lbs   Height:  ft  in
        

  
  
             Zip Code:  - 

  
    
      
    

 REPORTING PARTY
  *   *
  *   * *
   Legal relationship   * Family relationship
     

  *
  
             Zip Code:  - 

 
   
     
   
Willingness to Testify


 
 
 INCIDENT INFORMATION
           :  
  *Address: 
  
  
  
  Zip Code:   - 
 
       
 
          
 
  Select the institution reporting (if applicable):
    

 REPORTED TYPES OF ABUSE (check all that apply)
Abuse Resulted In:




   
Self Neglect Allegations:
 

Abuse Perpetrated by Others:




 


*Part [F]: REPORTER'S OBSERVATIONS, BELIEFS, AND STATEMENTS BY VICTIM IF AVAILABLE.
   DOES ALLEGED PERPETRATOR STILL HAVE ACCESS TO VICTIM?
   PROVIDE ANY KNOWN TIME FRAME (2 days, 1 week, ongoing, etc...)
   LIST ANY POTENTIAL DANGER FOR INVESTIGATOR (E.G.,ANIMALS,WEAPONS,COMMUNICABLE DISEASES, ETC.).


 TARGETED ACCOUNT
  Targeted Account Information:
      (last 4 digits)
    Type of Account:
Type of Account
    Trust Account:
Trust Account
    Power of Attorney:
Power of Attorney
    Direct Deposit:
Direct Deposit
    Other Accounts:
Other Accounts

OTHER PERSONS BELIEVED TO HAVE KNOWLEDGE OF ABUSE.
   FAMILY MEMBER OR OTHER PERSON RESPONSIBLE FOR VICTIM'S CARE. (If unknown, list contact person)
 
  
    
   Community relationship such as doctor, pharmacist, bank teller, etc Family relationship
  

  
  
             Zip Code:  - 

  
    
      
    

 
  

 WRITTEN REPORT (For Adult Protective Services use. Agencies listed will not be notified for you.)



































* Emergency responses must be submitted by phone
* On report submission you'll be directed to a confirmation page
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