Alaska Adult Protective Services Report of Harm
ALASKA ADULT PROTECTIVE SERVICES REPORT OF HARM
Before you use this: A mandatory reporter listed in AS 47.24.010(a) must report to the Department's vulnerable adult centralized intake office within 24 hours after first having reasonable cause for the belief while performing professional duties. The Department prefers its online intake system and provides an official paper form for fax or email. In an emergency, contact local law enforcement first, then report to APS. See the current APS reporting page.
To: Alaska Department of Health, Adult Protective Services, Centralized Reporting
Report date and time: [__/__/____], [TIME AND TIME ZONE]
Submission channel: ☐ Online portal ☐ Official paper form with this narrative attached ☐ Email to [email protected] ☐ Other Department-directed channel: [________]
Intake confirmation or recipient: [________________________________]
Reporter
| Item | Information |
|---|---|
| Name | [________________________________] |
| Role or relationship to adult | [________________________________] |
| Organization, if any | [________________________________] |
| Phone and safe callback time | [________________________________] |
| Email or mailing address | [________________________________] |
| Reporting capacity | ☐ Mandatory reporter under AS 47.24.010(a), role: [________] ☐ Other reporter |
| When I first had reasonable cause for concern | [DATE, TIME, TIME ZONE] |
Vulnerable adult
| Item | Information |
|---|---|
| Name and other names used | [________________________________] |
| Age or date of birth, if known | [________________________________] |
| Current location and contact information | [________________________________] |
| Safe way to contact the adult | [________________________________] |
| Communication, language, or access needs | [________________________________] |
| Observed reason the adult may need assistance to meet needs or seek help | [FACTS, NOT A DIAGNOSIS WITHOUT SUPPORT] |
AS 47.24.900(21) defines a vulnerable adult as a person at least 18 years old who, due to one of the listed conditions or circumstances, cannot meet their own needs or seek help without assistance. The observations above explain why this report may concern a vulnerable adult; APS makes its own assessment.
Harm or concern
Category observed or reported: ☐ Undue influence ☐ Abandonment ☐ Exploitation ☐ Abuse ☐ Neglect ☐ Self-neglect ☐ Uncertain
Date, time, and place of event or ongoing conditions: [________________________________]
What happened: [Describe the conduct, injuries, unmet needs, financial transactions, or other concerns chronologically. Separate personal observations from what another person reported. Quote significant statements accurately and identify their speaker and date.]
[____________________________________________________________]
[____________________________________________________________]
Nature and extent of harm or risk: [________________________________]
Immediate safety concern and requested contact: [________________________________]
Actions already taken: [Include medical care, safety steps, or law enforcement contact, with dates and names. Do not delay the APS report while collecting attachments.]
[____________________________________________________________]
Person believed involved, if known: [NAME, RELATIONSHIP, CONTACT DETAILS, AND FACTUAL BASIS. Write "unknown" if unknown. For self-neglect, a third-party perpetrator need not be named.]
Other witnesses or helpful contacts: [NAME, ROLE, CONTACT, AND WHAT EACH PERSON MAY KNOW]
Records, photographs, or other material available: [LIST ITEMS AND LOCATION. Provide sensitive records only through a channel the Department directs.]
Other information that may help APS investigate or protect the adult: [________________________________]
Emergency contact and submission record
| Item | Information |
|---|---|
| If law enforcement was contacted, agency, time, and officer | [________________________________] |
| Reason immediate action was needed | [________________________________] |
| APS submission time and method | [________________________________] |
| Confirmation number or person reached | [________________________________] |
| Follow-up information to supply | [________________________________] |
AS 47.24.010(e) directs a reporter who believes immediate action is needed to protect the adult from imminent serious physical harm and cannot immediately contact centralized intake to report to a police officer or village public safety officer. This does not replace a timely direct APS report when centralized intake can be reached.
I have described the facts known to me as accurately as I can and identified information received from others.
Reporter signature or name: [________________________________]
Date: [__/__/____]
Sources and references
- Alaska Statutes, AS 47.24.010, .050, .120, and .900 (accessed 2026-10-05).
- Alaska Department of Health, APS Report of Harm and its official paper form (accessed 2026-10-05).
Disclaimer: This template is informational and is not legal advice. AS 47.24.050 makes reports confidential subject to statutory use and disclosure rules; AS 47.24.120(a) provides immunity for a good-faith report under AS 47.24.010.
About this template
- Last updated
- October 5, 2026
- Citations checked
- October 5, 2026
- Jurisdiction
- Alaska
- Category
- Elder Law
Legal authority
- AS 47.24.010(a), (b), (d), (e) (reports of harm)
- AS 47.24.050(a) (confidentiality of reports)
- AS 47.24.120(a) (good-faith reporter immunity)
- AS 47.24.900(21) (vulnerable adult)
Elder law covers the legal needs that come with aging: planning for long-term care costs, protecting assets from being wiped out by a nursing home stay, handling incapacity, and responding to elder abuse or financial exploitation. The paperwork often has to coordinate with Medicaid rules, tax treatment, and state guardianship requirements, which is why small mistakes can cost a family a great deal of money or control over decisions.
Not legal advice
This template is provided for informational purposes. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Checked against the law it cites
A reviewer verified this template's legal citations against the official source on October 5, 2026.
AS 47.24.010(a) (checked October 5, 2026): "the following persons who, in the performance of their professional duties, have reasonable cause to believe that a vulnerable adult suffers from undue influence, abandonment, exploitation, abuse, neglect, or self-neglect shall, not later than 24 hours after first having cause for the belief, report the belief to the department's vulnerable adult centralized intake office"
AS 47.24.010(b) (checked October 5, 2026): "A report made under this section may include the name and address of the reporting person and must include (1) the name and contact information of the vulnerable adult; (2) information relating to the nature and extent of the undue influence, abandonment, exploitation, abuse, neglect, or self-neglect"
AS 47.24.010(d) (checked October 5, 2026): "This section does not prohibit any other person from reporting a harm under this section."
AS 47.24.010(e) (checked October 5, 2026): "If a person making a report under this section believes that immediate action is necessary to protect the vulnerable adult from imminent risk of serious physical harm due to undue influence, abandonment, exploitation, abuse, neglect, or self-neglect and the reporting person cannot immediately contact the department's vulnerable adult centralized intake office, the reporting person shall make the report to a police officer or a village public safety officer."
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