Alaska Adult Protective Services Report of Harm

ALASKA ADULT PROTECTIVE SERVICES REPORT OF HARM

TABLE OF CONTENTS

1. Submission Information
2. Reporter Identification
3. Vulnerable Adult — Subject of the Report
4. Categories of Harm
5. Narrative of Concerns
6. Alleged Perpetrator(s)
7. Imminent-Risk Assessment
8. Witnesses, Records, and Other Evidence
9. Photographs / X-rays
10. Mandatory-Reporter Certification
11. Statutory Notices and Immunity
12. Signature
13. Alaska Practice Notes
14. Sources and References

1. SUBMISSION INFORMATION

2. REPORTER IDENTIFICATION

The reporter is a mandatory reporter as one of the following persons listed in AS 47.24.010(a) (check all that apply):

• ☐ Physician or other licensed health care provider
• ☐ Mental health professional as defined in AS 47.30.915
• ☐ Pharmacist
• ☐ Administrator of a nursing home, residential facility, or assisted living home
• ☐ Guardian or conservator
• ☐ Police officer or village public safety officer
• ☐ Social worker
• ☐ Member of the clergy
• ☐ Long-term care service provider / direct-care worker
• ☐ Health, mental-health, or social-service practitioner not otherwise listed
• ☐ Employee of the Department of Health or Department of Family and Community Services
• ☐ Other category enumerated in AS 47.24.010(a): [________________________________]

3. VULNERABLE ADULT — SUBJECT OF THE REPORT

A "vulnerable adult" under AS 47.24.900 means a person 18 years of age or older who, because of incapacity, mental or physical illness, or disability, including extreme advanced age, is unable to meet the person's own needs or to seek help without assistance.

4. CATEGORIES OF HARM

Mark every category for which the reporter has reasonable cause to believe harm has occurred or is occurring (AS 47.24.900):

• ☐ Abandonment — desertion of a vulnerable adult by a caregiver under circumstances posing a serious risk to physical or mental health.
• ☐ Abuse — willful, intentional, or repeated infliction of physical injury, mental injury, sexual abuse, or sexual assault.
• ☐ Exploitation — unjust or improper use of a vulnerable adult or of the adult's resources for another's profit, advantage, or benefit.
• ☐ Neglect — intentional failure of a caregiver to provide essential care or services necessary to maintain the physical or mental health of the vulnerable adult.
• ☐ Self-Neglect — failure by a vulnerable adult, who is living alone and not receiving necessary care, to perform tasks essential to physical or mental health.
• ☐ Undue Influence — use of trust, dependency, fear, or power to substitute one person's will for the true desires of the vulnerable adult.

5. NARRATIVE OF CONCERNS

Provide a chronological, fact-specific narrative. Use direct observations and quoted statements where possible. Distinguish between what the reporter personally observed and what was reported second-hand.

[________________________________]

[________________________________]

[________________________________]

[________________________________]

[________________________________]

[________________________________]

[________________________________]

Specific observable indicators (check all that apply and describe in narrative above):

• ☐ Unexplained bruises, lacerations, burns, fractures, or pressure injuries
• ☐ Poor hygiene; soiled or inadequate clothing
• ☐ Significant weight loss; signs of dehydration or malnutrition
• ☐ Untreated medical conditions or missed medications
• ☐ Unsafe or unsanitary living conditions
• ☐ Sudden, unexplained changes in finances, deeds, beneficiaries, or POA
• ☐ Missing personal property, checks, debit cards, or jewelry
• ☐ Isolation from family / friends imposed by caregiver
• ☐ Inappropriate sexual contact or comments
• ☐ Verbal threats, intimidation, or controlling behavior by caregiver
• ☐ Adult unable or afraid to speak in caregiver's presence
• ☐ Other: [________________________________]

6. ALLEGED PERPETRATOR(S)

7. IMMINENT-RISK ASSESSMENT

• ☐ IMMINENT RISK — the vulnerable adult is in immediate danger of serious physical harm. Reporter has contacted [LAW ENFORCEMENT AGENCY] at [____] on [__/__/____] at [____]. Case / incident number: [________________________________].
• ☐ HEIGHTENED RISK — risk of harm is significant but not immediately imminent.
• ☐ STANDARD RISK — harm has occurred but the adult is presently safe.

Specific safety concerns:

[________________________________]

[________________________________]

8. WITNESSES, RECORDS, AND OTHER EVIDENCE

Records or documentation supporting this report (attach copies where permitted by law and reporter's role):

• ☐ Medical records / progress notes
• ☐ Photographs (see Section 9)
• ☐ Bank or financial statements
• ☐ Power of Attorney, deed, or trust instrument
• ☐ Text messages / emails / voicemails
• ☐ Facility incident reports
• ☐ Law enforcement reports
• ☐ Other: [________________________________]

9. PHOTOGRAPHS / X-RAYS

Under AS 47.24.019, a person required to make a report under AS 47.24.010 may take or cause to be taken photographs of the area of trauma visible on the vulnerable adult and, if medically indicated, may cause X-rays to be taken.

• ☐ Photographs taken on [__/__/____] by [____]; copies attached.
• ☐ X-rays ordered on [__/__/____] by [____]; copies attached.
• ☐ None taken.

10. MANDATORY-REPORTER CERTIFICATION

I certify that:

1. I am a person required to report under AS 47.24.010(a) and/or am voluntarily reporting under AS 47.24.011.
2. I have reasonable cause to believe that the vulnerable adult identified in Section 3 has suffered or is suffering from one or more of the categories of harm checked in Section 4.
3. I am submitting this report not later than 24 hours after first having that belief, as required by AS 47.24.010(a).
4. The information provided is true and correct to the best of my knowledge.

11. STATUTORY NOTICES AND IMMUNITY

• Immunity (AS 47.24.120). A person who in good faith makes a report under AS 47.24.010 or 47.24.011, or who participates in good faith in a related judicial or administrative proceeding, is immune from civil or criminal liability that might otherwise be incurred or imposed for making the report or participating.
• Confidentiality (AS 47.24.017). Reports and the identity of reporters are confidential and may be disclosed only as authorized by statute.
• Failure to report (AS 47.24.130). A person required to report under AS 47.24.010 who knowingly fails to comply commits a class B misdemeanor.
• Anti-retaliation. Employers, supervisors, and agencies are prohibited from retaliating against a person who in good faith makes a report or participates in an investigation under AS 47.24.

12. SIGNATURE

[________________________________]

[REPORTER NAME]

Title: [____]

Date / time signed: [__/__/____] at [____]

(For anonymous permissive reports under AS 47.24.011, signature is optional but the report should still document the date / time of the underlying belief.)

13. ALASKA PRACTICE NOTES

• Centralized Intake. All non-emergency reports flow through Centralized Reporting in the Adult Protective Services unit. The 24-hour clock under AS 47.24.010(a) begins when the mandatory reporter first has reasonable cause to believe harm — not when the harm occurred.
• Imminent danger. If the adult is in immediate danger, call 911 first, then APS. Village Public Safety Officers (VPSOs) and Alaska State Troopers may be the only available responders in many off-road communities.
• Cross-reporting. Long-term care facilities certified under 42 C.F.R. Part 483 must additionally report alleged abuse, neglect, exploitation, misappropriation of property, or injuries of unknown origin to the State Survey Agency: within 2 hours for abuse or serious bodily injury and within 24 hours for all other reportable incidents (see 42 C.F.R. § 483.12).
• Tribal communities. Where the vulnerable adult is an Alaska Native or American Indian, consider concurrent notice to the Tribal Family Services / Tribal Court of the relevant tribe, consistent with cooperative agreements between APS and Tribal entities.
• Power of attorney abuse. Many Alaska APS cases arise from financial exploitation by an agent under a durable POA. Reporters should preserve bank statements, deed records, and beneficiary changes for the investigator.
• Self-neglect. Self-neglect is the largest single category of APS reports nationwide and Alaska accepts these reports under AS 47.24.010, even where no third-party perpetrator exists.
• Confidentiality limits. HIPAA permits disclosure of protected health information to APS to report adult abuse, neglect, or domestic violence consistent with 45 C.F.R. § 164.512(c). Document the basis for disclosure in the patient record.

14. SOURCES AND REFERENCES

• AS 47.24 — Protection of Vulnerable Adults: https://www.akleg.gov/basis/statutes.asp#47.24
• AS 47.24.010 (Persons required to report; reports of harm): https://law.justia.com/codes/alaska/title-47/chapter-24/section-47-24-010/
• Alaska DOH — Adult Protective Services Report of Harm: https://health.alaska.gov/en/services/aps-report-harm/
• APS Online Intake: https://hssakprod.wellsky.com/intake/
• Alaska DOH — APS Mandated Reporters page: https://health.alaska.gov/en/resources/adult-protective-services-mandated-reporters/
• 7 AAC 78 (APS regulations)
• 42 C.F.R. § 483.12 (federal nursing-home abuse reporting)
• 45 C.F.R. § 164.512(c) (HIPAA disclosure to APS)
• Office of the Long Term Care Ombudsman of Alaska: https://akoltco.org/
• APS Telephone: 1-800-478-9996 (in-state) / 907-269-3666 (Centralized Reporting)
• APS Fax: 907-269-3648
• APS Email: [email protected]

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. If you believe a vulnerable adult is in immediate danger, call 911 first. Verify all hotlines, statutes, and forms against current Alaska Department of Health publications before relying on this template.