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: _______________________________________________

National Eldercare Locator: 1-800-677-1116 (to find local services)

SECTION 1: REPORT TYPE

1.1 Type of Report

Who is the potential victim?
☐ Adult age 60 or older (Elder)
☐ Vulnerable adult (under 60) with disability
☐ Adult with developmental disability
☐ Adult with mental illness
☐ Other vulnerable adult: _______________________________________________

1.2 Where Does the Person Live?

☐ Private residence (APS handles)
☐ Nursing home (contact Long-Term Care Ombudsman and/or APS)
☐ Assisted living facility (contact APS and/or Ombudsman)
☐ Group home (APS or licensing agency)
☐ 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?
☐ Yes - I understand my identity will be protected but investigation may be limited
☐ No - My identity may be disclosed if necessary for investigation

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: WHAT HAPPENS AFTER A REPORT?

9.1 APS Investigation Process

After you file a report, APS typically:

1. Screens the report to determine if it meets criteria for investigation
2. Assigns priority (emergency response, urgent, or non-urgent)
3. Contacts the adult for an assessment
4. Investigates the allegations
5. Determines findings (substantiated or unsubstantiated)
6. Provides or arranges services if the adult agrees
7. May refer to law enforcement if criminal activity is suspected

9.2 Response Times

• Emergency: Immediate to 24 hours
• Urgent: 24-72 hours
• Non-urgent: 3-5 business days

(Times vary by state and agency workload)

9.3 Confidentiality

• Reporter identity is confidential in most states
• Investigation information is generally confidential
• You may not receive details about the investigation outcome due to privacy laws

SECTION 10: REPORTER SIGNATURE

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

• Good faith reporters are protected from liability under state law
• Filing a knowingly false report may have legal consequences
• My identity will be kept confidential to the extent permitted by law
• APS may contact me for additional information

Signature: _________________________________

Date: _________________________________

Time: _________________________________

HOW TO FILE THIS REPORT

Option 1: Phone (Fastest for Emergencies)

Call your state's APS hotline number listed above.

Option 2: Online

Many states accept online reports through their APS website.

Option 3: Written

Mail or fax this completed form to your local APS office.

RESOURCES

National Elder Abuse Hotline: 1-800-677-1116

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

National Center on Elder Abuse: ncea.acl.gov

Long-Term Care Ombudsman Resource Center: ltcombudsman.org

This form is provided to help organize information for an Adult Protective Services report. If you suspect abuse, neglect, or exploitation of a vulnerable adult, please report to your local APS agency. You do not need to have proof - APS will investigate. Reports can often be made anonymously. Good faith reporters are protected by law.