Adult Protective Services Report

Purpose

This template provides a comprehensive framework for reporting suspected abuse, neglect, self-neglect, or exploitation of elderly or vulnerable adults to Adult Protective Services (APS).

Important Notice

EMERGENCY SITUATIONS:
- If someone is in immediate danger, call 911 first
- APS is NOT a first responder
- For imminent threats to life or safety, contact law enforcement

Confidentiality:
- Reports can usually be made confidentially or anonymously
- Your identity is protected from the alleged perpetrator
- Mandated reporters may be required to identify themselves

What is Adult Protective Services?

APS investigates reports of abuse, neglect, and exploitation of vulnerable adults. Services typically include:

• Investigation of reported abuse/neglect
• Safety assessments
• Coordination of protective services
• Referrals to community resources
• Case management
• Court intervention when necessary

Who is Eligible for APS Services?

Generally includes:
☐ Adults age 60 or older
☐ Adults age 18-59 with physical or mental impairment that substantially limits self-care
☐ Adults living in the community (not typically state-licensed facilities)

Note: Nursing home complaints are typically handled by the Long-Term Care Ombudsman and State Survey Agency, though APS may also investigate abuse.

Part 1: Reporting Party Information

About You (Reporter)

Your Relationship to the Alleged Victim

☐ Family member (Relationship: _____________)
☐ Friend
☐ Neighbor
☐ Healthcare provider
☐ Social worker
☐ Law enforcement
☐ Financial institution employee
☐ Clergy
☐ Other: _________________________________

Reporting Status

☐ I am a mandated reporter in my state
☐ I am NOT a mandated reporter
☐ Unsure of mandated reporter status

Mandated reporters in most states include:
- Healthcare professionals
- Social workers
- Mental health professionals
- Law enforcement
- Financial institution employees
- Clergy (varies by state)

Confidentiality Preference

☐ I wish to remain confidential (identity protected from alleged perpetrator)
☐ I wish to remain anonymous (identity not recorded)
☐ My identity may be disclosed if needed

Part 2: Alleged Victim Information

Person Suspected of Being Abused/Neglected

Physical Description (if helpful for locating)

Current Location

☐ At home address listed above
☐ Hospital (Name: _________________)
☐ Nursing home (Name: _________________)
☐ Assisted living (Name: _________________)
☐ With family/friend (Address: _________________)
☐ Unknown
☐ Other: _________________________________

Living Situation

☐ Lives alone
☐ Lives with spouse/partner
☐ Lives with adult child (Name: _________________)
☐ Lives with other family (Name: _________________)
☐ Lives with caregiver (Name: _________________)
☐ Lives with alleged perpetrator
☐ Homeless
☐ Other: _________________________________

Vulnerability Factors

☐ Cognitive impairment/dementia
☐ Mental illness
☐ Physical disability
☐ Sensory impairment (vision/hearing)
☐ Limited mobility
☐ Dependent on others for daily care
☐ Social isolation
☐ Limited English proficiency
☐ Other: _________________________________

Known Diagnoses/Conditions

__________________________________________________________________

__________________________________________________________________

Primary Care Physician (if known)

Part 3: Alleged Perpetrator Information

Suspected Abuser/Neglecter (if known)

Relationship to Victim

☐ Spouse/partner
☐ Adult child
☐ Grandchild
☐ Other family (Relationship: _____________)
☐ Caregiver (paid)
☐ Caregiver (unpaid)
☐ Friend/acquaintance
☐ Neighbor
☐ Stranger
☐ Self (self-neglect)
☐ Unknown
☐ Other: _________________________________

Access to Victim

☐ Lives with victim
☐ Has regular access to victim's home
☐ Provides care to victim
☐ Has access to victim's finances
☐ Has Power of Attorney
☐ Is legal guardian
☐ Other: _________________________________

Is the Alleged Perpetrator Currently Present with Victim?

☐ Yes
☐ No
☐ Unknown

Does the Alleged Perpetrator Have Weapons?

☐ Yes (Describe: _________________)
☐ No
☐ Unknown

Part 4: Type of Abuse/Neglect Suspected

Categories (check all that apply)

Physical Abuse:
☐ Hitting, slapping, kicking, punching
☐ Pushing, shoving
☐ Burning
☐ Use of weapons
☐ Force-feeding
☐ Physical restraint (inappropriate)
☐ Other physical harm: _________________________________

Emotional/Psychological Abuse:
☐ Verbal threats
☐ Intimidation
☐ Humiliation
☐ Isolation from family/friends
☐ Controlling behavior
☐ Harassment
☐ Other: _________________________________

Sexual Abuse:
☐ Unwanted sexual contact
☐ Sexual assault
☐ Forced to watch sexual acts
☐ Photographed inappropriately
☐ Other: _________________________________

Neglect (by caregiver):
☐ Failure to provide food
☐ Failure to provide water
☐ Failure to provide shelter
☐ Failure to provide clothing
☐ Failure to provide medical care
☐ Failure to provide medications
☐ Failure to provide hygiene assistance
☐ Abandonment
☐ Other: _________________________________

Self-Neglect:
☐ Refusal to eat/drink
☐ Refusal of necessary medical care
☐ Living in unsafe/unsanitary conditions
☐ Hoarding
☐ Poor personal hygiene (self-caused)
☐ Inability to manage finances
☐ Other: _________________________________

Financial Exploitation:
☐ Theft of money/property
☐ Misuse of Power of Attorney
☐ Forged signatures
☐ Unauthorized use of credit/debit cards
☐ Coerced to change will/estate documents
☐ Scams/fraud
☐ Other: _________________________________

Part 5: Description of Alleged Abuse/Neglect

Incident Details

When did the suspected abuse/neglect occur?

☐ Single incident - Date: _________________
☐ Multiple incidents - Dates: _________________
☐ Ongoing situation - Duration: _________________
☐ Unknown when it occurred

Where did the suspected abuse/neglect occur?

☐ Victim's home
☐ Perpetrator's home
☐ Healthcare facility
☐ Public location
☐ Other: _________________________________

Detailed Description

Describe what happened in as much detail as possible:
(Include what you saw, heard, or were told; who was involved; when it happened)

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

Physical Signs Observed

☐ Bruises (Location: _________________)
☐ Burns (Location: _________________)
☐ Cuts/lacerations
☐ Broken bones (suspected)
☐ Unexplained injuries
☐ Dehydration
☐ Malnutrition/weight loss
☐ Poor hygiene
☐ Pressure sores
☐ Untreated medical conditions
☐ Over-sedation
☐ Other: _________________________________

Behavioral Signs Observed

☐ Fear of caregiver/specific person
☐ Withdrawal
☐ Agitation
☐ Depression
☐ Confusion (new or worsening)
☐ Changes in behavior
☐ Reluctance to speak openly
☐ Other: _________________________________

Environmental Conditions Observed

☐ Unsafe living conditions
☐ Unsanitary conditions
☐ Lack of food
☐ Lack of heat/cooling
☐ Lack of utilities
☐ Hoarding
☐ Pest infestation
☐ Structural hazards
☐ Other: _________________________________

Part 6: Evidence and Witnesses

Available Evidence

☐ Photographs
☐ Medical records
☐ Financial records
☐ Written statements
☐ Video/audio recordings
☐ Other: _________________________________

Witnesses

Has Victim Made Statements About the Abuse/Neglect?

☐ Yes ☐ No ☐ Victim unable to communicate

If yes, what did the victim say?

__________________________________________________________________

__________________________________________________________________

Part 7: Current Safety Assessment

Immediate Danger Assessment

Is the victim in immediate danger?
☐ Yes - If yes, call 911
☐ No
☐ Uncertain

Risk factors present:
☐ Perpetrator is currently present
☐ Perpetrator has access to victim
☐ Threats have been made
☐ Weapons are present
☐ History of violence
☐ Victim is medically fragile
☐ No safe place for victim
☐ Other: _________________________________

Medical Attention Needed

☐ Victim needs immediate medical attention
☐ Victim has untreated medical conditions
☐ Victim appears stable
☐ Unknown

Support System

Does the victim have anyone who can help protect them?
☐ Yes (Who: _________________)
☐ No
☐ Unknown

Part 8: Prior Reports and Interventions

Previous APS Reports

☐ No previous APS reports (to my knowledge)
☐ Previous reports made:

Other Interventions

☐ Law enforcement involvement (Date: _________)
☐ Hospital visits related to abuse (Date: _________)
☐ Restraining/protective orders
☐ Guardianship proceedings
☐ Other: _________________________________

Part 9: Emergency Contacts for Victim

Family/Friends Who Can Help

Other Important Contacts

Part 10: How to Report to APS

State APS Contact Information

Find your state APS:
- Eldercare Locator: 1-800-677-1116
- Online: eldercare.acl.gov

Your State APS:

Methods for Reporting

☐ Phone - Call the APS hotline (recommended for urgent situations)
☐ Online - Submit through state's online portal (if available)
☐ In Person - Visit local APS office
☐ Written - Mail or fax written report

Information to Have Ready When Calling

☐ Victim's name, address, and phone
☐ Victim's date of birth or age
☐ Type of abuse/neglect suspected
☐ Description of what happened
☐ When and where it occurred
☐ Perpetrator information (if known)
☐ Current safety concerns
☐ Your contact information (unless anonymous)

Part 11: Sample Written Report to APS

[DATE]

Adult Protective Services
[AGENCY ADDRESS]
[CITY, STATE ZIP]

RE: Report of Suspected Elder Abuse/Neglect

Dear Adult Protective Services:

I am writing to report suspected [type of abuse/neglect] of [Victim Name], a [age]-year-old [man/woman] residing at [address].

VICTIM INFORMATION:
- Name: [Full Name]
- Date of Birth: [DOB]
- Address: [Address]
- Phone: [Phone]
- Current Location: [Where victim is now]

MY INFORMATION:
- Name: [Your Name - or "Anonymous"]
- Relationship to Victim: [Relationship]
- Phone: [Your Phone]
- [Mandated Reporter Status if applicable]

ALLEGED PERPETRATOR:
- Name: [If known]
- Relationship to Victim: [Relationship]
- Address: [If known]
- Currently with victim: [Yes/No]

DESCRIPTION OF SUSPECTED ABUSE/NEGLECT:

[Provide detailed description including:
- What you observed or were told
- When the incidents occurred
- Where they occurred
- Any physical signs observed
- Any statements made by the victim]

SAFETY CONCERNS:

[Describe any immediate safety concerns, risk factors, or urgent needs]

WITNESSES/EVIDENCE:

[List any witnesses or available evidence]

PRIOR REPORTS:

[Note any prior reports or interventions]

I am concerned for [Victim Name]'s safety and well-being and request that APS investigate this matter promptly.

Please contact me at [phone/email] if you need additional information. [Or: I wish to remain anonymous.]

Sincerely,

_________________________________
[Your Signature]

[Your Printed Name]

Part 12: What Happens After You Report

APS Investigation Process

Step 1: Intake
☐ APS receives and reviews report
☐ Determines if report meets criteria for investigation
☐ Assigns priority level based on urgency

Step 2: Investigation
☐ APS worker contacts victim
☐ Conducts home visit
☐ Interviews victim, perpetrator, witnesses
☐ Assesses safety and needs
☐ Gathers evidence

Step 3: Determination
☐ Substantiated - Evidence supports abuse/neglect occurred
☐ Unsubstantiated - Insufficient evidence
☐ Inconclusive - Unable to determine

Step 4: Service Plan (if substantiated)
☐ Safety plan developed
☐ Services coordinated
☐ Referrals made
☐ Legal action if necessary

Timeline

Follow-Up

☐ APS may contact you for additional information
☐ You may call to check on status (provide case number)
☐ Investigation details are usually confidential

Part 13: Other Reporting Options

Additional Agencies to Consider

Law Enforcement:
- For crimes (assault, theft, fraud)
- For immediate safety concerns
- Local police: _________________________________

Long-Term Care Ombudsman:
- For nursing home or assisted living complaints
- Contact: _________________________________

State Licensing Agency:
- For facility violations
- Contact: _________________________________

State Attorney General:
- For financial exploitation
- Consumer protection: _________________________________

Social Security Administration:
- For benefit theft/misuse
- 1-800-772-1213

Part 14: Resources for Victims

National Resources

Local Resources

Part 15: Protection from Retaliation

Your Rights as a Reporter

Good Faith Immunity:
Most states protect reporters from civil or criminal liability when reports are made in good faith.

Confidentiality:
☐ Your identity is generally protected
☐ Alleged perpetrators should not learn who reported
☐ Anonymous reports are accepted in most states

If You Experience Retaliation

☐ Document all incidents
☐ Report retaliation to APS
☐ Contact law enforcement if threatened
☐ Consult with attorney if needed

Part 16: Report Tracking

Your Report Record

Follow-Up Log

Signatures

Reporter Certification:

I certify that the information in this report is true and accurate to the best of my knowledge. I understand that filing a false report may be subject to penalties.

Signature: _________________________________ Date: _______________

Print Name: _________________________________

☐ I am a mandated reporter and understand my reporting obligations

This template is for informational purposes only. If you suspect elder abuse or neglect, contact your local Adult Protective Services agency or call the Eldercare Locator at 1-800-677-1116. In emergencies, call 911.