REPORT OF SUSPECTED DEPENDENT ADULT/ELDER ABUSE

 VICTIM
 
  First Name:  *Last Name:  Alias:
  *Age (or approx. age):  OR DOB:  SSN:  

  Language  Race:    
  Education Level:  Gender:    
  Living Arrangements:  Other Case Number:

  Primary


Home Phone:  
Work Phone:   ext: 
Cell/Other:  

  Address:
  City:
  Zip Code:  - 
 
  Current Location: (if different from address)
  

 Vulnerabilities:





  SUSPECTED ABUSER
 
  First Name:  *Last Name:  Alias:
  Age:   DOB: SSN:  
  Collateral Type: ?   Resource Type: ? Relation to AV: ?
  Gender:   Race:
  Weight:  lbs   Height:  ft  in
  Eyes:   Hair:   

  Address Line 1:
  Address Line 2:
  City:    State:       Zip Code:  - 

  Primary


Home Phone:  
Work Phone:   ext: 
Cell/Other:  

 REPORTING PARTY

  *First Name:  *Last Name:
  *Email:   *Work Place: *Occupation:
  Resource Type: ?   *Relation to AV: ?
  Gender:   Race:

  *Address Line 1:
  Address Line 2:
  City:    State:       Zip Code:  - 

  Primary


Home Phone:  
Work Phone:   ext: 
Cell/Other:  
Willing to Testify


 
 INCIDENT INFORMATION

  Date and Time of this incident:         :  
  *Address: 
  Line 1:
  Line 2:
  City:
  Zip Code:   - 
 
  Phone Number (###) ###-####:     
 
  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:   If Other, please specify:

  Abuse Perpetrated by Others:






 If Other, please specify:

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:
    Account Number:  (last 4 digits)
    Type of Account:
    Trust Account:
    Power of Attorney:
    Direct Deposit:
    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)
 
  First Name: Last Name:
  DOB: SSN:  
  Collateral Type: ? Relation to AV: ?
  Gender: Race:

  Address Line 1:
  Address Line 2:
  City:      State:     Zip Code:  - 

  Primary


Home Phone:  
Work Phone:   ext: 
Cell/Other:  

  Please provide any other information that would help us investigate:
  

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

Agency
First Name
Last Name

Mailed
Address
Date
Faxed
Fax Number
Date

Agency
First Name
Last Name

Mailed
Address
Date
Faxed
Fax Number
Date

Agency
First Name
Last Name

Mailed
Address
Date
Faxed
Fax Number
Date


* ?

* ?