Connecticut Protective Services for the Elderly (PSE) Report — Mandated Reporter

CONNECTICUT PROTECTIVE SERVICES FOR THE ELDERLY (PSE) REPORT

TABLE OF CONTENTS

1. Reporter Information and Mandated-Reporter Status
2. Subject Elderly Person
3. Type of Abuse / Neglect / Exploitation Suspected
4. Alleged Perpetrator(s)
5. Factual Narrative
6. Risk and Safety Assessment
7. Witnesses and Other Sources of Information
8. Documentary Evidence Attached
9. 24-Hour Deadline Compliance
10. Reporter Attestation and Statutory Acknowledgments
11. Distribution and Service
12. Practice Notes
13. Sources and References

1. REPORTER INFORMATION AND MANDATED-REPORTER STATUS

Mandated-Reporter Category (check all that apply — Conn. Gen. Stat. § 17b-451(a)):

• ☐ Physician / Surgeon / Resident / Intern
• ☐ Registered or Licensed Practical Nurse
• ☐ Physician Assistant / APRN
• ☐ Medical Examiner
• ☐ Dentist / Dental Hygienist
• ☐ Optometrist / Chiropractor / Podiatrist / Pharmacist
• ☐ Psychologist / Marital and Family Therapist / Clinical Social Worker
• ☐ Professional Counselor / Alcohol and Drug Counselor
• ☐ Sexual Assault Counselor / Domestic Violence Counselor
• ☐ Police Officer / Probation Officer
• ☐ Clergy
• ☐ Nursing Home Administrator / Nurses' Aide / Orderly
• ☐ Person paid to care for an elderly person in a long-term care facility, residential care home, or chronic disease hospital
• ☐ Patients' advocate
• ☐ Licensed practical nurse, medical examiner, dental hygienist, psychologist, physical therapist, occupational therapist, speech-language pathologist, or any individual paid for caring for an elderly person
• ☐ Permissive (non-mandated) reporter

☐ I am reporting in my professional capacity.
☐ I am reporting in my personal capacity.

2. SUBJECT ELDERLY PERSON

Does the elder have capacity to consent to protective services? ☐ Yes ☐ No ☐ Unclear / suspected lack of capacity

3. TYPE OF ABUSE / NEGLECT / EXPLOITATION SUSPECTED

(Check all that apply — definitions per Conn. Gen. Stat. § 17b-450 and § 17a-412.)

• ☐ Physical abuse — willful infliction of physical pain or injury
• ☐ Mental anguish / emotional abuse — willful infliction of mental anguish
• ☐ Sexual abuse — non-consensual sexual contact, exploitation, or assault
• ☐ Neglect by caretaker — willful deprivation of services necessary to maintain physical and mental health
• ☐ Self-neglect — inability of elderly person to provide for own basic needs (PSE may still investigate)
• ☐ Financial exploitation — wrongful taking, misappropriation, or use of an elderly person's funds, property, or assets
• ☐ Abandonment — desertion or willful forsaking by caretaker
• ☐ Need for protective services — services to prevent or remedy harm
• ☐ Other: [__________]

4. ALLEGED PERPETRATOR(S)

(Add additional perpetrators in attached supplement.)

5. FACTUAL NARRATIVE

5.1 Date and time observations made: [__/__/____ at __:__ a.m./p.m.]

5.2 Location of observations: [________________________________]

5.3 What the reporter observed (first-person, factual, non-conclusory):

[Provide a chronological factual narrative. Describe physical findings, statements made by the elder, statements made by the alleged perpetrator, financial transactions, condition of living quarters, medication management, and any other directly observed facts. Use quotation marks for verbatim statements. Avoid speculation. Identify the source of any second-hand information.]

[________________________________]

[________________________________]

[________________________________]

5.4 Specific injuries, bruising, or physical findings (if any):

5.5 Financial-exploitation indicators (if any):

• ☐ Unexplained withdrawals or transfers
• ☐ Sudden change to deed, will, beneficiary designation, or POA
• ☐ Unpaid bills despite adequate funds
• ☐ Missing belongings or valuables
• ☐ New "friend" or caregiver isolating elder
• ☐ Forged signatures
• ☐ Recent estate-planning changes inconsistent with elder's prior intent

5.6 Neglect / self-neglect indicators (if any):

• ☐ Malnutrition / dehydration / weight loss
• ☐ Pressure ulcers / poor hygiene
• ☐ Unsafe living conditions / hoarding
• ☐ Lack of needed assistive devices
• ☐ Medication mismanagement
• ☐ Untreated medical conditions

6. RISK AND SAFETY ASSESSMENT

6.1 Is the elder in immediate danger? ☐ Yes ☐ No

If yes, has 9-1-1 / law enforcement been contacted? ☐ Yes — agency: [__________], time: [__:__] ☐ No

6.2 Does the elder require emergency medical care? ☐ Yes ☐ No — if yes, transported to: [__________]

6.3 Is the alleged perpetrator currently with the elder? ☐ Yes ☐ No ☐ Unknown

6.4 Is the elder cognitively able to refuse protective services? ☐ Yes ☐ No ☐ Unclear

6.5 Has the elder expressed a desire for help? ☐ Yes ☐ No ☐ Could not be determined

6.6 Other vulnerable adults in the same household? ☐ Yes (describe): [__________] ☐ No

7. WITNESSES AND OTHER SOURCES OF INFORMATION

8. DOCUMENTARY EVIDENCE ATTACHED

• ☐ Photographs of injuries / living conditions (date-stamped)
• ☐ Medical / nursing notes
• ☐ Bank or brokerage statements
• ☐ Copies of suspicious legal documents (POA, deed, will)
• ☐ Incident reports
• ☐ Email / text correspondence
• ☐ Voicemail transcript
• ☐ Other: [__________]

(Mark all attachments as exhibits and label A, B, C, etc.)

9. 24-HOUR DEADLINE COMPLIANCE

The reporter certifies that the oral report was made within twenty-four (24) hours of forming reasonable cause to suspect, in compliance with Conn. Gen. Stat. § 17b-451(b).

10. REPORTER ATTESTATION AND STATUTORY ACKNOWLEDGMENTS

10.1 Good-Faith Attestation. I declare under penalty of false statement (Conn. Gen. Stat. § 53a-157b) that the foregoing is true and correct to the best of my knowledge, information, and belief, and that this report is made in good faith based on my own observations or on information I reasonably believe to be reliable.

10.2 Statutory Immunity. I understand that pursuant to Conn. Gen. Stat. § 17b-451(g), any person who in good faith makes a report or testifies in any administrative or judicial proceeding arising from such report shall be immune from any civil or criminal liability on account of such report or testimony, except for liability arising from perjury.

10.3 Anti-Retaliation Protection. I understand that Conn. Gen. Stat. § 17b-451 protects mandated reporters from retaliation, discharge, or discrimination by any employer, principal, or contracting party arising from a good-faith report.

10.4 Confidentiality. I understand that the identity of a reporter and the contents of this report are confidential under Conn. Gen. Stat. § 17b-451(j) and the DSS Uniform Policy Manual, subject to limited statutory exceptions.

10.5 Continuing Duty. I acknowledge that I have a continuing duty to report any additional information learned subsequent to this filing.

Reporter Signature: [________________________________]

Print Name: [REPORTER NAME]

Date: [__/__/____]

Time: [__:__ a.m./p.m.]

11. DISTRIBUTION AND SERVICE

Original to:

State of Connecticut, Department of Social Services
Protective Services for the Elderly (PSE)
55 Farmington Avenue, Hartford, CT 06105
Toll-Free Hotline: 1-888-385-4225 (Mon-Fri, 8:00 AM - 4:30 PM)
After-Hours / Weekends / Holidays: 2-1-1 (or 1-800-203-1234 out-of-state)
Email / Fax: per current DSS instructions on the W-675 form

Copies to (as appropriate and consistent with confidentiality limits):

• ☐ Local law enforcement — agency: [__________]
• ☐ State / Regional Long-Term Care Ombudsman (if institutional setting): 1-866-388-1888
• ☐ Connecticut Department of Public Health, Facility Licensing and Investigations Section (FLIS) (if institutional setting)
• ☐ Reporter's employer / risk management (per internal policy)
• ☐ Reporter's personal file (retain)

12. PRACTICE NOTES

• Who is "elderly." Any person aged 60 or older. (Distinct from CT's separate adult protective services system for younger adults with disabilities under Conn. Gen. Stat. § 17b-456.)
• Reasonable cause. The reporter need not have proof — only a reasonable basis to suspect. When in doubt, report.
• 24-hour clock. Runs from the moment the reporter forms reasonable cause to suspect, not from the moment of observation. Document carefully.
• Self-neglect. PSE investigates self-neglect even when no perpetrator exists. Reporters often hesitate; this is unnecessary.
• Financial exploitation reporting to financial institutions. Conn. Gen. Stat. § 17b-451 also imposes reporting duties on certain financial-institution personnel. Coordinate with the institution's compliance officer.
• Probate Court intervention. If the elder lacks capacity and refuses needed services, DSS may petition the Probate Court under Conn. Gen. Stat. § 17b-454 for an order authorizing protective services or appointing a conservator under Conn. Gen. Stat. § 45a-644 et seq.
• Criminal referral. Serious cases may be referred for prosecution under Conn. Gen. Stat. §§ 53a-321 to 53a-323b (crimes against elderly, blind, or disabled persons), Conn. Gen. Stat. § 53a-122 (larceny by defrauding a public community / first-degree larceny), or applicable assault statutes.
• Penalty for non-reporting. $500 fine plus mandatory retraining; intentional failure to report = class C misdemeanor (first offense), class A misdemeanor (subsequent).
• Retention. Maintain a copy of this completed form, the W-675 receipt confirmation, and any PSE intake number for at least seven (7) years (or longer per professional record-retention rules).

13. SOURCES AND REFERENCES

• DSS Protective Services for the Elderly — https://portal.ct.gov/dss/social-work-services/social-work-services/protective-services-for-the-elderly
• DSS W-675 Referral Form — https://portal.ct.gov/-/media/Departments-and-Agencies/DSS/Social-Work-Services/W-675-Referral-6_2023-1.pdf
• Conn. Gen. Stat. Chapter 319dd (Protective Services for the Elderly) — https://www.cga.ct.gov/current/pub/chap_319dd.htm
• Conn. Gen. Stat. § 17b-450 (Definitions) — https://www.cga.ct.gov/current/pub/chap_319dd.htm#sec_17b-450
• Conn. Gen. Stat. § 17b-451 (Mandatory reporting) — https://www.cga.ct.gov/current/pub/chap_319dd.htm#sec_17b-451
• Conn. Gen. Stat. § 17b-452 (Investigation) — https://www.cga.ct.gov/current/pub/chap_319dd.htm#sec_17b-452
• Conn. Gen. Stat. § 17a-412 (Reports — additional definitions) — https://www.cga.ct.gov/current/pub/chap_319a.htm
• Conn. Gen. Stat. §§ 53a-321 et seq. (Crimes against elderly) — https://www.cga.ct.gov/current/pub/chap_952.htm
• Connecticut Judicial Branch Law About Elder Abuse — https://www.jud.ct.gov/lawlib/law/elderabuse.htm
• Connecticut Long-Term Care Ombudsman Program — https://portal.ct.gov/LTCOP
• Elder Justice CT — https://elderjusticect.org
• United Way of Connecticut — Elder Abuse Laws and Mandated Reporting — https://uwc.211ct.org/elder-abuse-laws-and-mandated-reporting-connecticut/
• DSS toll-free PSE hotline: 1-888-385-4225 (Mon-Fri, 8:00 AM - 4:30 PM)
• After-hours: 2-1-1 (or 1-800-203-1234 outside CT)

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Mandatory reporters must report suspected abuse, neglect, exploitation, or abandonment of any person aged 60 or older to DSS Protective Services for the Elderly within 24 hours under Conn. Gen. Stat. § 17b-451. Use this template alongside the official W-675 form and the toll-free hotline.