Arkansas Adult Protective Services Report — Mandated Reporter Maltreatment Report

ARKANSAS ADULT PROTECTIVE SERVICES — MALTREATMENT REPORT

TABLE OF CONTENTS

1. Reporter Information
2. Statutory Basis for Report
3. Subject (Alleged Victim) Information
4. Alleged Maltreater Information
5. Description of Maltreatment
6. Evidence and Witnesses
7. Risk Assessment
8. Actions Taken to Date
9. Notifications and Distribution
10. Immunity and Confidentiality Acknowledgment
11. Reporter Certification
12. Sources and References

1. REPORTER INFORMATION

2. STATUTORY BASIS FOR REPORT

2.1. This report is filed pursuant to:

• ☐ Ark. Code Ann. § 12-12-1708 — mandated-reporter duty;
• ☐ Ark. Code Ann. § 12-12-1709 — reporting procedures;
• ☐ Permissive report by non-mandated reporter under § 12-12-1707 (any person may report);
• ☐ Long-term-care facility incident — also reported to Office of Long-Term Care under Ark. Code Ann. § 20-10-1207.

2.2. Subject of report (check one or more):

• ☐ "Endangered adult" (§ 12-12-1703) — adult 18 or older who is found to be in a situation or condition that poses a danger to himself or herself and is unable to protect himself or herself due to a physical or mental impairment, or because of the lack of essential services for the maintenance of physical or mental health.
• ☐ "Impaired adult" (§ 12-12-1703) — adult 18 or older whose ability to perform the normal activities of daily living or to provide for his or her own care or protection is impaired due to a mental or physical condition or because of advanced age.
• ☐ Resident of a long-term-care facility (regardless of impairment status).

2.3. Type of maltreatment alleged (§ 12-12-1703; check all that apply):

• ☐ Physical abuse — intentional infliction of physical pain, injury, mental anguish, or unreasonable confinement;
• ☐ Sexual abuse — sexual contact, sexual penetration, deviate sexual activity;
• ☐ Neglect — failure to provide necessary food, medical care, supervision, or services;
• ☐ Self-neglect — failure of an endangered or impaired adult to provide for his or her own care;
• ☐ Exploitation — illegal or unauthorized use of an adult's funds, assets, property, power of attorney, or guardianship;
• ☐ Financial exploitation — taking, misusing, or concealing funds or property;
• ☐ Abandonment — desertion by a caregiver who has assumed responsibility.

3. SUBJECT (ALLEGED VICTIM) INFORMATION

3.1. Name: [________________________________]

3.2. Date of birth / approximate age: [__/__/____] / [____]

3.3. Sex: ☐ M ☐ F ☐ Other / unknown

3.4. Race / ethnicity (if known): [________________________________]

3.5. Current address (or facility name and address): [________________________________]

3.6. Telephone: [________________________________]

3.7. Apparent impairments: [________________________________]

3.8. Primary language / communication needs: [________________________________]

3.9. Current location at time of report: ☐ Own home ☐ Family member's home ☐ Nursing facility ☐ Assisted living ☐ Hospital ☐ Other [________________________________]

3.10. Legal representative (guardian, POA, conservator): [________________________________]

3.11. Subject's awareness of report: ☐ Aware ☐ Unaware ☐ Unknown

4. ALLEGED MALTREATER INFORMATION

5. DESCRIPTION OF MALTREATMENT

5.1. Date(s) of maltreatment (or date range): [__/__/____] to [__/__/____]

5.2. Location(s) where maltreatment occurred: [________________________________]

5.3. Specific facts giving rise to reasonable cause to suspect maltreatment (be specific; describe what was observed, said, or discovered; do not editorialize):

[________________________________________________________________________________]

[________________________________________________________________________________]

[________________________________________________________________________________]

5.4. Observed injuries / physical findings (location, size, color, age):

[________________________________________________________________________________]

5.5. Subject's statements (verbatim if possible; use quotation marks):

[________________________________________________________________________________]

5.6. For financial exploitation, describe transactions, amounts, and timing:

[________________________________________________________________________________]

5.7. Pattern or prior incidents (known or suspected):

[________________________________________________________________________________]

6. EVIDENCE AND WITNESSES

6.1. Documentary evidence in reporter's possession or known to exist:

• ☐ Medical records / progress notes
• ☐ Photographs of injuries / conditions
• ☐ Bank statements, canceled checks, cards
• ☐ Power-of-attorney / guardianship / trust documents
• ☐ Facility records / incident reports
• ☐ Surveillance / body-camera video
• ☐ Text messages / emails / voicemails
• ☐ Other: [________________________________]

6.2. Witnesses:

6.3. Has any evidence been preserved or sequestered? [________________________________]

7. RISK ASSESSMENT

7.1. Imminent danger to subject? ☐ Yes ☐ No Explain: [________________________________]

7.2. Was 911 / law enforcement contacted? ☐ Yes ☐ No Agency: [____________] Report #: [____________]

7.3. Is the subject able to consent to services and protect himself or herself? ☐ Yes ☐ No ☐ Diminished

7.4. Does the subject have decisional capacity to refuse intervention? ☐ Yes ☐ No ☐ Unclear — physician evaluation recommended.

7.5. Emergency removal under Ark. Code Ann. § 9-20-110 (Adult Maltreatment Custody Act) recommended? ☐ Yes ☐ No

7.6. Recommended protective actions: [________________________________]

8. ACTIONS TAKEN TO DATE

• ☐ Telephonic report to Adult Maltreatment Hotline 1-800-482-8049 on [__/__/____] at [__:__].
• ☐ Report to Office of Long-Term Care 1-800-582-4887 on [__/__/____].
• ☐ Report to law enforcement: [________________________________]
• ☐ Notification to facility administrator (per § 12-12-1708(c) institutional procedure).
• ☐ Medical examination obtained at [____________] on [__/__/____].
• ☐ Photographs taken / evidence preserved.
• ☐ Subject moved to safer location: [____________].
• ☐ Notification to long-term care ombudsman (1-501-682-2441 / 1-800-582-4887).
• ☐ Notification to prosecuting attorney for [____________] County.
• ☐ Notification to licensing board: [____________].

9. NOTIFICATIONS AND DISTRIBUTION

This written report is being transmitted to:

• ☐ Arkansas DHS, Division of Aging, Adult, and Behavioral Health Services (DAABHS) — Adult Protective Services
• ☐ Office of Long-Term Care, DHS Division of Provider Services and Quality Assurance — [email protected] / fax 501-682-8540
• ☐ Local law enforcement agency: [____________]
• ☐ Prosecuting Attorney, [____________] Judicial District
• ☐ Long-Term Care Ombudsman: [____________]
• ☐ Facility administrator: [____________]
• ☐ Reporter's institutional file
• ☐ Other: [____________]

10. IMMUNITY AND CONFIDENTIALITY ACKNOWLEDGMENT

10.1. Statutory immunity. Pursuant to Ark. Code Ann. § 12-12-1713, any person, official, or institution participating in good faith in the making of a report, the taking of photographs, the removal of an endangered or impaired adult, or any judicial proceeding resulting therefrom shall have immunity from any civil or criminal liability that otherwise might be incurred, except in the case of bad faith or malicious purpose.

10.2. Reporter confidentiality. Pursuant to Ark. Code Ann. § 12-12-1716 and § 12-12-1717, the identity of the reporter and the content of the report are confidential and may be released only as authorized by statute or court order.

10.3. Penalty for failure to report. A mandated reporter who knowingly fails to report or who knowingly prevents another from reporting is guilty of a Class B misdemeanor for a first offense, with enhanced penalties for subsequent offenses, under Ark. Code Ann. § 12-12-1720, in addition to civil liability for damages proximately caused by the failure.

10.4. No retaliation. Employers may not discharge, discipline, or retaliate against a mandated reporter who in good faith makes a report.

Reporter initials: [______]

11. REPORTER CERTIFICATION

I, the undersigned reporter, certify that I have reasonable cause to suspect that the subject identified above has been or is at risk of being maltreated as defined by the Arkansas Adult and Long-Term Care Facility Resident Maltreatment Act. I have made (or caused to be made) an immediate telephonic report to the Adult Maltreatment Hotline, and the foregoing written report is true and correct to the best of my knowledge, information, and belief. I make this report in good faith and without malice.

[________________________________]

[REPORTER NAME]

Title: [____________________]

Date: [__/__/____]

Time: [__:__] ☐ AM ☐ PM

12. SOURCES AND REFERENCES

• Ark. Code Ann. § 12-12-1701 et seq. (Adult and Long-Term Care Facility Resident Maltreatment Act) — https://law.justia.com/codes/arkansas/title-12/subtitle-2/chapter-12/subchapter-17/
• Arkansas DHS — Adult Protective Services — https://humanservices.arkansas.gov/divisions-shared-services/aging-adult-behavioral-health-services/adult-protective-services/
• Arkansas DHS — Mandated Reporters of Adult Maltreatment — https://humanservices.arkansas.gov/divisions-shared-services/aging-adult-behavioral-health-services/adult-protective-services/mandated-reporters-of-adult-maltreatment/
• Adult Maltreatment Hotline: 1-800-482-8049 (24 hours / 7 days)
• Office of Long-Term Care Complaint Hotline: 1-800-582-4887
• DHS "Report a Concern" portal — https://humanservices.arkansas.gov/report-a-concern/
• Arkansas Attorney General — Elder Abuse Resources — https://arkansasag.gov/divisions/public-protection/seniors/elder-abuse/
• Arkansas Long-Term Care Ombudsman — https://arombudsman.dhs.arkansas.gov/
• Adult Maltreatment Custody Act, Ark. Code Ann. § 9-20-101 et seq. — https://law.justia.com/codes/arkansas/title-9/subtitle-2/chapter-20/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. The duty to report under Arkansas law is immediate and personal; this written form supplements but does not substitute for the required telephonic report to 1-800-482-8049. Confirm current statute text before relying on any cited section.