Adult Protective Services (APS) Report — At-Risk Adult Mistreatment / Self-Neglect

ADULT PROTECTIVE SERVICES (APS) REPORT — AT-RISK ADULT MISTREATMENT / SELF-NEGLECT

TABLE OF CONTENTS

1. Reporter Identification and Status
2. Recipients of Report
3. At-Risk Adult Information
4. Alleged Perpetrator(s) Information
5. Type and Description of Mistreatment
6. Witnesses, Evidence, and Prior Reports
7. Risk Assessment and Immediate Safety
8. Statutory Acknowledgments — Mandatory Reporting and Immunity
9. County APS and Statewide Hotline Reference
10. Signature, Verification, and Distribution
11. Colorado Practice Notes
12. Sources and References

1. REPORTER IDENTIFICATION AND STATUS

1.1. Reporter Status (check one):

• ☐ Mandatory reporter under C.R.S. § 18-6.5-108. (Statute lists, among others: health-care providers; hospital and long-term care facility personnel; first responders including EMS, fire, and law enforcement; victim advocates; psychologists, addiction counselors, professional counselors, marriage and family therapists, registered psychotherapists; clergy; care-facility staff; home-care agencies; social workers and county human services staff; and others. See § 18-6.5-108(1).)
• ☐ Permissive reporter (not statutorily mandated, reporting in good faith under C.R.S. § 26-3.1-102).

1.2. Anonymity.

• ☐ Reporter requests confidentiality to the extent permitted by law (12 C.C.R. 2518-1 § 7.110.4).
• ☐ Reporter does not request confidentiality.

2. RECIPIENTS OF REPORT

This report is being submitted to:

• ☐ Law Enforcement Agency (REQUIRED for mandatory reporters under § 18-6.5-108): [NAME], [ADDRESS], [PHONE], Officer/Case #: [__________]
• ☐ County Adult Protective Services: [COUNTY] County Department of Human Services — APS Unit, [ADDRESS], [PHONE]
• ☐ Statewide CDHS Reporting Line: 1-844-CO-4-KIDS (1-844-264-5437) — Reference #: [__________]
• ☐ Long-Term Care Ombudsman (if at-risk adult resides in a licensed nursing facility, assisted living residence, or similar facility): [NAME / OFFICE], [PHONE]
• ☐ CDPHE Health Facilities and Emergency Medical Services Division (if facility-based abuse/neglect): 1-800-886-7689
• ☐ Other: [________________________________]

3. AT-RISK ADULT INFORMATION

3.1. At-Risk Adult Status. Check all that apply (per C.R.S. §§ 26-3.1-101 and 18-6.5-102):

• ☐ At-risk adult (18+) — susceptible to mistreatment or self-neglect because unable to perform or obtain services necessary for health, safety, or welfare, OR lacks sufficient understanding/capacity to make or communicate responsible decisions.
• ☐ At-risk elder (70+) — within the protected class for mandatory criminal reporting under § 18-6.5-108.
• ☐ At-risk adult with IDD — has an intellectual or developmental disability as defined by C.R.S. § 25.5-10-202.
• ☐ At-risk juvenile (under 18) — referred to child protective services in addition.

3.2. Functional and Medical Status.

3.3. Caregiver / Surrogate Decision-Maker (if any).

4. ALLEGED PERPETRATOR(S) INFORMATION

For each alleged perpetrator, provide as much information as known. If unknown, write "UNKNOWN."

5. TYPE AND DESCRIPTION OF MISTREATMENT

5.1. Type(s) of Mistreatment. Check all that apply (definitions per C.R.S. § 26-3.1-101 and § 18-6.5-102):

• ☐ Physical abuse — non-accidental infliction of bodily injury, pain, or impairment.
• ☐ Sexual abuse / sexual exploitation — non-consensual sexual contact, conduct, or exploitation.
• ☐ Caretaker neglect — failure to provide food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision, or other necessary treatment.
• ☐ Self-neglect — at-risk adult substantially endangers own health, safety, welfare, or life by not seeking or obtaining necessary services.
• ☐ Exploitation / financial exploitation — wrongful taking, misuse, or concealment of money, assets, or property of an at-risk adult, or wrongful use of a position of trust.
• ☐ Theft by undue influence, fraud, deception, or breach of fiduciary duty.
• ☐ Abandonment — desertion of the at-risk adult by a person who has assumed responsibility for care.
• ☐ Unlawful restraint / chemical restraint / unlawful seclusion.

5.2. Detailed Narrative. Describe what happened, when, where, how the reporter learned of it, and any direct observations. Use objective, specific language; quote statements verbatim where possible; identify the source of each fact.

[NARRATIVE — ATTACH ADDITIONAL PAGES AS NEEDED]

[________________________________]

[________________________________]

[________________________________]

[________________________________]

[________________________________]

5.3. Date(s) of Incident(s).

5.4. Visible Injuries / Indicators (if applicable).

6. WITNESSES, EVIDENCE, AND PRIOR REPORTS

6.1. Witnesses.

6.2. Documentary / Physical Evidence (attach copies, do not destroy originals).

• ☐ Photographs of injuries / conditions
• ☐ Medical records / discharge summaries
• ☐ Bank statements, checks, ATM records
• ☐ Recorded threats / voicemails / texts / emails
• ☐ Power of Attorney / Will / Trust documents
• ☐ Facility incident reports or care plans
• ☐ Surveillance / body-cam footage
• ☐ Other: [________________________________]

6.3. Prior Reports.

7. RISK ASSESSMENT AND IMMEDIATE SAFETY

• ☐ At-risk adult is in immediate danger — 911 has been called.
• ☐ Alleged perpetrator has continuing access to the at-risk adult.
• ☐ At-risk adult is medically unstable and requires emergency evaluation.
• ☐ At-risk adult lacks decisional capacity and an emergency guardianship or protective order may be warranted (C.R.S. § 15-14-312; § 13-14-101 et seq.).
• ☐ Facility-based incident requires CDPHE survey or facility self-report.
• ☐ Financial exploitation is ongoing — banks/brokerages may be notified consistent with § 11-10-104 (financial institution exploitation reporting) and Senior Safe Act, 12 U.S.C. § 3423.

Recommended Protective Actions:

[________________________________]

[________________________________]

8. STATUTORY ACKNOWLEDGMENTS — MANDATORY REPORTING AND IMMUNITY

8.1. Mandatory Reporting (C.R.S. § 18-6.5-108). A mandatory reporter who has reasonable cause to believe that an at-risk elder (70+) or at-risk adult with IDD has been mistreated, OR is at imminent risk of mistreatment, must report to a law enforcement agency where the mistreatment occurred not later than twenty-four (24) hours after observing or discovering the mistreatment. Willful failure to report is a class 3 misdemeanor under § 18-6.5-108(2).

8.2. APS Reporting (C.R.S. § 26-3.1-102). Any person may report suspected mistreatment OR self-neglect of an at-risk adult to the county department of human services. The county department must make a face-to-face interview within prescribed timeframes (typically immediately for emergencies, 1–3 business days otherwise) and complete an investigation under 12 C.C.R. 2518-1.

8.3. Immunity (C.R.S. § 26-3.1-102(4); § 18-6.5-108(3)). A person who in good faith reports mistreatment or self-neglect, or who participates in an investigation, judicial proceeding, or providing protective services, is immune from any civil or criminal liability that might otherwise result. Immunity does NOT extend to a person alleged to have committed the mistreatment.

8.4. Anti-Retaliation (C.R.S. § 26-3.1-104). Retaliation against an at-risk adult or a reporter is prohibited and may give rise to civil liability and disciplinary action.

8.5. Confidentiality. APS records are confidential under C.R.S. § 26-3.1-102(7). Disclosure is limited to law enforcement, courts, statutorily authorized recipients, and as ordered by a court.

Reporter Initials acknowledging Sections 8.1–8.5: [____]

9. COUNTY APS AND STATEWIDE HOTLINE REFERENCE

9.1. Statewide. Colorado Adult Abuse and Neglect / Child Abuse and Neglect Hotline — 1-844-CO-4-KIDS (1-844-264-5437), available 24 hours / 7 days / 365 days. The statewide line routes calls to the appropriate county APS unit. Use 911 for emergencies.

9.2. County APS. Reports are investigated by the county department of human/social services where the at-risk adult resides. To find the correct county APS intake number, see https://cdhs.colorado.gov/aps or contact the statewide line.

9.3. Long-Term Care Ombudsman. For at-risk adults in licensed long-term care facilities, the State Long-Term Care Ombudsman Program can investigate quality-of-care concerns. Statewide: 1-800-288-1376. State Ombudsman: https://www.coombudsman.org.

9.4. CDPHE Health Facility Complaints. For complaints concerning licensed health-care facilities (nursing facilities, assisted living): 1-800-886-7689; https://cdphe.colorado.gov/health-facility-complaints.

10. SIGNATURE, VERIFICATION, AND DISTRIBUTION

I declare under penalty of perjury under the laws of the State of Colorado that the foregoing report is true and correct to the best of my knowledge and belief, and that I am submitting it in good faith pursuant to C.R.S. § 26-3.1-102 and, where applicable, § 18-6.5-108.

Reporter Signature: [________________________________]

Print Name: [________________________________]

Title / Capacity: [________________________________]

Date: [__/__/____]

Distribution Log:

11. COLORADO PRACTICE NOTES

• Verbal report first, paperwork second. The mandatory-reporter clock runs from observation/discovery; do not wait to complete this template before placing the verbal call. Use this template to memorialize and supplement the call.
• Both criminal and civil tracks. § 18-6.5-108 (criminal mandatory reporting to law enforcement) and § 26-3.1-102 (APS administrative reporting) operate in parallel. A facility staff member may need to make BOTH reports for the same incident.
• Statutory history. The mandatory-reporting framework for at-risk elders (and at-risk adults with IDD) was created by S.B. 13-111 (effective May 16, 2013), with the criminal reporting mandate becoming operative July 1, 2014. Subsequent legislation has periodically expanded the list of mandatory reporters; verify the current text of § 18-6.5-108 before relying on a particular professional category.
• At-risk juvenile. If the suspected victim is under 18, the Children's Code mandatory reporting statute (C.R.S. § 19-3-304) controls and reports go to the Colorado Child Abuse and Neglect Hotline (same number, 1-844-264-5437) or a local law enforcement agency.
• Facility self-reporting. Licensed long-term care facilities have separate self-reporting duties to CDPHE under 6 C.C.R. 1011-1 (Chapter V); a facility's compliance with internal policies does not satisfy the APS or law enforcement reporting duties.
• Financial institutions. C.R.S. § 11-10-104 authorizes financial institutions to delay or refuse suspect transactions and to report suspected exploitation; coordinate with the bank's BSA/AML compliance officer where exploitation is suspected.
• Immediate protective orders. A protection order under C.R.S. § 13-14-101 et seq. may be available; emergency guardianship/conservatorship under C.R.S. § 15-14-312 (guardian) and § 15-14-405 (conservator) may also be required. Consult a probate or elder law attorney.
• Records retention. Reporters should keep contemporaneous notes, photographs, and copies of this report in a secure location. APS investigation records are confidential by statute; do not assume the reporter will receive a copy of the case file.

12. SOURCES AND REFERENCES

• Colorado Department of Human Services — Adult Protective Services — https://cdhs.colorado.gov/aps
• Report mistreatment or self-neglect of an at-risk adult — https://cdhs.colorado.gov/report-mistreatment-or-self-neglect-of-an-at-risk-adult
• Mandatory Reporting of Adult Mistreatment — https://cdhs.colorado.gov/mandatory-reporting-of-adult-mistreatment
• C.R.S. § 26-3.1-101 et seq. (Protective Services for Adults) — https://leg.colorado.gov/colorado-revised-statutes
• C.R.S. § 18-6.5-101 et seq. (Wrongs to At-Risk Persons)
• C.R.S. § 18-6.5-108 (Mandatory Reporting; Penalties) — https://law.justia.com/codes/colorado/title-18/article-6-5/section-18-6-5-108/
• 12 C.C.R. 2518-1 (CDHS APS Rules) — https://www.sos.state.co.us/CCR/
• Colorado Long-Term Care Ombudsman — https://www.coombudsman.org/
• CDPHE Health Facility Complaints — 1-800-886-7689 — https://cdphe.colorado.gov/health-facility-complaints
• Statewide Reporting Line — 1-844-CO-4-KIDS (1-844-264-5437)
• S.B. 13-111 (2013); subsequent amendments to § 18-6.5-108

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. It does not substitute for any statutorily required verbal report. Mandatory reporters must comply with the 24-hour verbal report obligation to law enforcement under C.R.S. § 18-6.5-108. An attorney licensed in Colorado must review this template before use in any judicial, administrative, or licensure proceeding.