Adult Protective Services Complaint

Adult Protective Services (APS) Complaint Form

EMERGENCY NOTICE

CALL 911 IMMEDIATELY IF:

• The person is in immediate physical danger
• A crime is in progress
• The person needs emergency medical care

STATE APS CONTACT INFORMATION

State: _______________________________________________

APS Hotline Number: _______________________________________________

APS Website: _______________________________________________

Hours: _______________________________________________

Eldercare Locator: 1-800-677-1116 (to find local services; this is not the state APS reporting number)

SECTION 1: REPORT TYPE

1.1 Type of Report

Who is the potential victim?
These are descriptive fields; the receiving agency determines whether the report falls within its jurisdiction.
☐ Older adult — approximate age: [____]
☐ Adult with a disability or support need — describe: [DETAILS]
☐ Adult with developmental disability
☐ Adult with mental illness
☐ Other vulnerable adult: _______________________________________________

1.2 Where Does the Person Live?

☐ Private residence
☐ Nursing home
☐ Assisted living facility
☐ Group home
☐ Homeless
☐ Other: _______________________________________________

SECTION 2: PERSON REPORTING

2.1 Reporter Information

Your Name: _______________________________________________

Address:
_______________________________________________
_______________________________________________

Daytime Phone: _______________________________________________

Cell/Evening Phone: _______________________________________________

Email: _______________________________________________

Best Time to Call: _______________________________________________

2.2 Reporter Status

Are you a mandated reporter under state law?
☐ Yes - Profession: _______________________________________________
☐ No

Your relationship to the adult:
☐ Family member (specify): _______________________________________________
☐ Friend
☐ Neighbor
☐ Healthcare provider
☐ Social services provider
☐ Bank/financial institution employee
☐ Clergy
☐ Law enforcement
☐ Other professional: _______________________________________________
☐ Concerned citizen
☐ Anonymous

2.3 Confidentiality Request

Do you wish to remain anonymous/confidential?
☐ I request confidentiality to the extent available under the receiving agency's rules
☐ I am willing to be contacted and identified if the agency requires it

Ask the receiving agency whether an anonymous report is accepted and how reporter information may be used or disclosed.

SECTION 3: VULNERABLE ADULT INFORMATION

3.1 Identifying Information

Full Name: _______________________________________________

Also Known As (nicknames, maiden name): _______________________________________________

Date of Birth: _______________________________________________

Approximate Age (if DOB unknown): _______________________________________________

Gender: ☐ Male ☐ Female ☐ Other ☐ Unknown

Race/Ethnicity: _______________________________________________

Primary Language: _______________________________________________

Interpreter Needed? ☐ Yes ☐ No

3.2 Location

Current Address:
_______________________________________________
_______________________________________________
_______________________________________________

Directions to Location (if needed):
_______________________________________________
_______________________________________________

Phone Number: _______________________________________________

3.3 Living Situation

Does the adult live:
☐ Alone
☐ With spouse/partner
☐ With family member(s): _______________________________________________
☐ With caregiver
☐ In facility: _______________________________________________
☐ With other(s): _______________________________________________

Who has access to the home?
_______________________________________________

3.4 Physical/Mental Condition

Describe the adult's physical condition:
_______________________________________________
_______________________________________________

Describe the adult's mental/cognitive condition:
☐ Alert and oriented
☐ Confused at times
☐ Dementia/Memory impairment
☐ Mental illness (specify): _______________________________________________
☐ Developmental disability
☐ Unknown

Does the adult need help with daily activities?
☐ Yes - Describe: _______________________________________________
☐ No
☐ Unknown

Is the adult mobile?
☐ Ambulatory without assistance
☐ Uses walker/cane/wheelchair
☐ Bedridden
☐ Unknown

SECTION 4: ALLEGED ABUSE, NEGLECT, OR EXPLOITATION

4.1 Type of Allegation (Check All That Apply)

☐ PHYSICAL ABUSE
Examples: Hitting, slapping, pushing, kicking, burning, inappropriate restraint

☐ EMOTIONAL/PSYCHOLOGICAL ABUSE
Examples: Threats, humiliation, intimidation, isolation, harassment, controlling behavior

☐ SEXUAL ABUSE
Examples: Any non-consensual sexual contact or activity

☐ NEGLECT BY CAREGIVER
Examples: Failure to provide food, water, shelter, clothing, hygiene, medication, medical care, supervision

☐ SELF-NEGLECT
Examples: Adult is unable or unwilling to provide for own basic needs (food, water, hygiene, housing, medical care, safety)

☐ FINANCIAL EXPLOITATION
Examples: Theft, misuse of funds, fraud, scams, undue influence, unauthorized use of property

☐ ABANDONMENT
Examples: Desertion by a caregiver

☐ OTHER
Specify: _______________________________________________

4.2 Detailed Description

Describe exactly what happened or what you observed:
(Be as specific as possible - include dates, times, locations, exact observations, and statements made)

_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

4.3 Timeline

When did this happen?
☐ Today
☐ Within the past week (Date: _______________)
☐ Within the past month
☐ Longer than a month ago (When: _______________)
☐ Ongoing

How long has this been happening?
_______________________________________________

Is this the first incident?
☐ Yes
☐ No - This has happened before (describe): _______________________________________________

4.4 How Did You Learn About This?

☐ I directly observed the abuse/neglect/exploitation
☐ The adult told me
☐ Another person told me (who: _______________)
☐ I noticed signs/indicators
☐ Other: _______________________________________________

SECTION 5: ALLEGED PERPETRATOR INFORMATION

5.1 Alleged Perpetrator(s)

Is the alleged perpetrator known?
☐ Yes - Complete below
☐ No - Skip to Section 6

Name: _______________________________________________

Relationship to Adult:
☐ Spouse/Partner
☐ Son/Daughter
☐ Other family (specify): _______________________________________________
☐ Paid caregiver
☐ Unpaid caregiver
☐ Friend/Acquaintance
☐ Facility staff
☐ Unknown person
☐ Other: _______________________________________________

Address: _______________________________________________

Phone: _______________________________________________

Physical Description (if name unknown):
_______________________________________________

Does this person live with the adult? ☐ Yes ☐ No ☐ Unknown

Does this person have Power of Attorney? ☐ Yes ☐ No ☐ Unknown

Does this person control the adult's finances? ☐ Yes ☐ No ☐ Unknown

5.2 Additional Perpetrators

☐ There are additional alleged perpetrators

Names and details:
_______________________________________________
_______________________________________________

SECTION 6: CURRENT CONDITION AND DANGER

6.1 Adult's Current Condition

Describe the adult's current physical condition:
☐ No visible injuries
☐ Injuries observed (describe): _______________________________________________
☐ Appears malnourished
☐ Poor hygiene/unkempt
☐ Medical condition appears untreated
☐ Other concerns: _______________________________________________

Describe the adult's current emotional state:
☐ Appears fearful/anxious
☐ Appears depressed
☐ Appears withdrawn
☐ Appears confused
☐ Other: _______________________________________________

6.2 Level of Danger

Is the adult in immediate danger?
☐ YES - Call 911 if not already done
☐ No immediate danger but situation is serious
☐ Concern but no immediate danger
☐ Unknown

Does the alleged perpetrator have access to weapons?
☐ Yes - Type: _______________________________________________
☐ No
☐ Unknown

Has the alleged perpetrator made threats?
☐ Yes - Describe: _______________________________________________
☐ No
☐ Unknown

6.3 Immediate Needs

Does the adult have any immediate needs?
☐ Emergency medical care
☐ Food/water
☐ Safe shelter
☐ Medication
☐ Protection from abuser
☐ Other: _______________________________________________

SECTION 7: ADDITIONAL INFORMATION

7.1 Witnesses

Are there witnesses who can provide information?

7.2 Prior Reports

Has this situation been reported before?
☐ No
☐ Yes - Reported to: _______________________________________________
When: _______________________________________________
Outcome: _______________________________________________

7.3 Other Agencies Involved

Are any other agencies already involved?
☐ Police/Sheriff
☐ Hospital/Medical provider
☐ Mental health agency
☐ Home health agency
☐ Other: _______________________________________________

7.4 Legal Representatives

Does the adult have any of the following?

Power of Attorney - Name: _______________________________________________
Phone: _______________________________________________

Guardian/Conservator - Name: _______________________________________________
Phone: _______________________________________________

7.5 Emergency Contacts

Family/Emergency Contact for the Adult:
Name: _______________________________________________
Phone: _______________________________________________
Relationship: _______________________________________________

SECTION 8: ADDITIONAL DETAILS

Any other information that would help investigators:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

SECTION 9: SUBMISSION AND FOLLOW-UP

Receiving state agency or other authority: [AGENCY NAME, VERIFIED CONTACT, AND DATE CHECKED]

Reporting channel accepted by that agency: [HOTLINE / ONLINE / WRITTEN / OTHER]

Report submitted on: [__/__/____] at [TIME] by [METHOD]

Confirmation or reference number, if provided: [NUMBER / NONE]

Follow-up contact and date, if provided: [NAME / DATE / NONE]

Ask the receiving agency about its screening process, response time, confidentiality rules, and whether it will provide a status update. If the danger is immediate, call 911 rather than relying on a report-processing estimate.

SECTION 10: REPORTER SIGNATURE

I am filing this report in good faith. I understand that:

• I have identified what I directly observed and what others told me
• I have described uncertainties and have not presented a suspicion as a proven finding
• I will ask the receiving agency about confidentiality and any applicable reporter protections
• APS may contact me for additional information

Signature: _________________________________

Date: _________________________________

Time: _________________________________

HOW TO FILE THIS REPORT

Option 1: Phone

Call the verified state APS hotline number listed above if the agency accepts phone reports. For an immediate emergency, call 911.

Option 2: Online

Use the state APS website listed above if it offers an online report for this situation.

Option 3: Written

Mail or fax this completed form only if the receiving agency confirms that method and address.

RESOURCES

Eldercare Locator: 1-800-677-1116

National Domestic Violence Hotline: 1-800-799-7233

National Center on Elder Abuse: ncea.usc.edu

Long-Term Care Ombudsman Resource Center: ltcombudsman.org

This form helps organize observations and concerns for a report. The receiving agency decides whether it accepts the report and what action to take under the law and procedures that apply there.