Arizona Adult Protective Services (APS) Report of Vulnerable Adult Abuse, Neglect, or Exploitation

Arizona Adult Protective Services Report — Vulnerable Adult Abuse, Neglect, or Exploitation

CRITICAL — Make the Statutory Report First

Part I — Reporter Information

Part II — Vulnerable Adult ("Victim")

A "vulnerable adult" under A.R.S. § 46-451(A)(12) is an individual age 18 or older who is unable to protect himself from abuse, neglect, or exploitation by others because of a physical or mental impairment.

Part III — Type of Abuse, Neglect, or Exploitation Reported

Check ALL that apply. Definitions per A.R.S. § 46-451:

☐ Physical abuse — intentional infliction of physical injury, unreasonable confinement, or unlawful use of physical or chemical restraint
☐ Sexual abuse / sexual assault of vulnerable adult
☐ Emotional/psychological abuse — willful infliction of mental anguish or unreasonable confinement
☐ Neglect — pattern of conduct resulting in deprivation of food, water, medication, medical services, shelter, cooling, heating, or other care necessary to maintain physical/mental health
☐ Self-neglect — vulnerable adult unable to perform self-care, posing serious risk
☐ Abandonment — desertion by caregiver who has assumed responsibility
☐ Financial exploitation (A.R.S. § 46-456) — illegal or improper use of vulnerable adult's resources by person in position of trust and confidence
☐ Other: [________________________________]

Part IV — Description of Suspected Abuse / Neglect / Exploitation

A. What happened

[________________________________________________________________]
[________________________________________________________________]
[________________________________________________________________]

B. Date(s), time(s), and place(s)

C. Observed indicators

☐ Bruises, lacerations, burns, fractures (describe: [__________])
☐ Pressure ulcers / decubitus / skin breakdown
☐ Dehydration / malnutrition / unexplained weight loss
☐ Soiled clothing, body odor, untreated medical conditions
☐ Over- or under-medication / missing prescriptions
☐ Fearful, withdrawn, or agitated behavior in caregiver's presence
☐ Sudden inability to pay bills; unusual bank withdrawals or transfers
☐ New deed, will, POA, or beneficiary change benefiting suspected exploiter
☐ Missing personal property, jewelry, mail, identification documents
☐ Caregiver isolating victim from family, friends, or other professionals
☐ Other: [________________________________]

D. Source of reporter's knowledge

☐ Direct observation ☐ Statement by victim ☐ Statement by witness ☐ Medical records ☐ Financial records ☐ Other: [____________]

Part V — Suspected Perpetrator(s)

(Repeat for additional alleged perpetrators on attached page.)

Part VI — Witnesses and Other Sources

Part VII — Financial Exploitation Specifics (A.R.S. § 46-456)

If financial exploitation is suspected, complete:

Part VIII — Actions Already Taken

☐ Phone report to APS made on [__/__/____] at [____] — Confirmation #: [____________]
☐ Online APS web intake submitted on [__/__/____] — Confirmation #: [____________]
☐ Local law enforcement notified — Department: [____________] Report #: [____________]
☐ 911 / EMS contacted on [__/__/____]
☐ Long-Term Care Ombudsman notified
☐ Facility administrator notified — name: [____________]
☐ Adult Protective Services Registry check requested
☐ Petition for emergency guardianship/conservatorship filed
☐ Banking institution fraud unit notified (A.R.S. § 46-456 banking referral)
☐ Other: [____________]

Part IX — Statutory Provisions Referenced

Part X — Reporter Certification

I certify that the information stated above is true and correct to the best of my knowledge and that I am making this report in good faith pursuant to A.R.S. § 46-454. I understand that good-faith reporters are immune from civil or criminal liability under A.R.S. § 46-453(I) and that retaliation against me is prohibited under A.R.S. § 46-454(L).

Reporter signature: ____________________________

Printed name: ____________________________ Date: [__/__/____]

Part XI — APS Use Only

Sources and References

• AZ DES Adult Protective Services: https://des.az.gov/services/aging-and-adult/adult-protective-services
• AZ DES Mandated Reporters: https://des.az.gov/services/basic-needs/adult-protective-services/mandated-reporters
• A.R.S. § 46-454 (mandatory reporting): https://www.azleg.gov/ars/46/00454.htm
• A.R.S. § 46-455 (vulnerable adult civil cause of action): https://www.azleg.gov/ars/46/00455.htm
• A.R.S. § 46-456 (financial exploitation): https://www.azleg.gov/ars/46/00456.htm
• AZ APS Statutes (DES summary): https://des.az.gov/services/aging-and-adult/adult-protective-services/arizona-adult-protective-services-statutes
• APS Online Web Intake: https://hssazapsprod.wellsky.com/assessments/?WebIntake=1F74FCDA-C6AB-4192-9CEE-F8D20DE98850
• Arizona State Bar APSA Civil Jury Instructions (2025): https://www.azbar.org/media/5qxcznop/apsa-raji-instructions-2025-06-04.pdf