DC Adult Protective Services Report (Mandatory Reporter)

DC ADULT PROTECTIVE SERVICES REPORT — DISTRICT OF COLUMBIA

TABLE OF CONTENTS

1. Hotline Notice and Time-Stamp
2. Reporter Identification
3. Adult at Risk — Identification
4. Alleged Perpetrator(s)
5. Nature of Abuse, Neglect, Self-Neglect, or Exploitation
6. Basis of Reporter's Knowledge
7. Immediate Risk and Safety Concerns
8. Mandatory-Reporter Certification and Immunity
9. Submission Channels and Confidentiality
10. DC Practice Notes
11. Sources and References

1. HOTLINE NOTICE AND TIME-STAMP

The DC APS Hotline is operated 24 hours a day, 7 days a week, by the Department of Human Services Adult Protective Services Division.

2. REPORTER IDENTIFICATION

2.1. Reporter category (check all that apply). I am reporting in my capacity as:

• ☐ Conservator
• ☐ Court-appointed advocate (including for persons with intellectual disability)
• ☐ Guardian
• ☐ Health-care administrator
• ☐ Licensed health professional (physician, nurse, dentist, therapist, etc.)
• ☐ Police officer
• ☐ Humane officer
• ☐ Bank manager
• ☐ Financial manager / fiduciary
• ☐ Social worker
• ☐ Voluntary reporter (not a mandatory category, reporting under D.C. Code § 7-1903(b))

2.2. Mandatory-report acknowledgment. I understand that, as a mandatory reporter under D.C. Code § 7-1903(a), I am required to report immediately upon forming a substantial cause to believe that an adult is in need of protective services because of abuse, neglect, self-neglect, or exploitation, and that failure to do so may result in penalties under D.C. Code § 7-1912.

3. ADULT AT RISK — IDENTIFICATION

3.1. Statutory eligibility. D.C. Code § 7-1901 defines an "adult in need of protective services" as a person 18 years of age or older who is unable to perform or obtain services necessary to maintain physical or mental health and lacks the capacity to consent because of abuse, neglect, self-neglect, or exploitation.

4. ALLEGED PERPETRATOR(S)

Provide a separate row for each suspected perpetrator. Mark "Unknown" where information is not available.

5. NATURE OF ABUSE, NEGLECT, SELF-NEGLECT, OR EXPLOITATION

5.1. Type of harm reported (check all that apply):

• ☐ Physical abuse (hitting, slapping, restraint, sexual assault)
• ☐ Emotional / psychological abuse (threats, humiliation, isolation)
• ☐ Sexual abuse / non-consensual sexual contact
• ☐ Neglect by another (caregiver failing to provide food, shelter, hygiene, medical care)
• ☐ Self-neglect (adult unable to meet own needs and lacking decisional capacity)
• ☐ Financial exploitation (unauthorized account use, undue influence, theft, fraud, coerced power of attorney, deed transfer)
• ☐ Abandonment by caregiver
• ☐ Medication misuse / chemical restraint
• ☐ Other ( [DESCRIBE] )

5.2. Narrative. Describe in chronological order, in objective and observable terms, the events, statements, injuries, financial transactions, or living conditions giving rise to substantial cause to believe protective services are needed. Identify dates, times, places, witnesses, and the source of each fact (personal observation vs. statement by another).

[NARRATIVE — attach additional pages as needed]

5.3. Documentary evidence enclosed:

• ☐ Photographs of injuries / living conditions
• ☐ Medical records or chart notes
• ☐ Bank or financial-account statements
• ☐ Power-of-attorney, deed, or trust documents
• ☐ Recorded statements / 911 transcripts
• ☐ Police incident report number [________]
• ☐ Other ( [DESCRIBE] )

6. BASIS OF REPORTER'S KNOWLEDGE

Pursuant to D.C. Code § 7-1903(c), a report should disclose the basis of the reporter's knowledge. Indicate all that apply:

• ☐ Personal observation of the adult on [__/__/____]
• ☐ Direct statement by the adult on [__/__/____]
• ☐ Statement by family member / caregiver on [__/__/____] ( [NAME] )
• ☐ Review of medical / financial records ( [DESCRIBE] )
• ☐ Forensic-accounting analysis
• ☐ Multidisciplinary team consultation
• ☐ Other ( [DESCRIBE] )

I have a substantial cause to believe that the adult identified in Section 3 is in need of protective services because of the conduct or condition described in Section 5.

7. IMMEDIATE RISK AND SAFETY CONCERNS

7.1. Immediacy of risk:

• ☐ Imminent danger to life or limb — recommend immediate dispatch of MPD / EMS in addition to APS response
• ☐ High risk — protective intervention recommended within 24 hours
• ☐ Moderate risk — protective intervention recommended within 72 hours
• ☐ Lower risk — routine APS investigation requested

7.2. Recommended protective measures:

• ☐ Welfare check by Metropolitan Police Department
• ☐ Emergency removal under D.C. Code § 7-1905
• ☐ Petition for guardian or conservator (D.C. Code § 21-2041 et seq.)
• ☐ Civil protection order
• ☐ Freeze of financial accounts / fiduciary referral
• ☐ Coordination with DC Health Long-Term Care Ombudsman if adult resides in a licensed facility (Section 11)
• ☐ Coordination with US Attorney's Office Elder Justice Unit for criminal referral

7.3. Access barriers. Identify gatekeepers, locked-door situations, hostile caregivers, language access needs, or service-animal considerations that may impede APS response: [________________________________].

8. MANDATORY-REPORTER CERTIFICATION AND IMMUNITY

8.1. Good-faith certification. I certify that I have made this report in good faith, based on information I believe to be true and accurate as of the date of this report.

8.2. Statutory immunity. Pursuant to D.C. Code § 7-1908, "Any person who reports an alleged case of abuse, neglect, self-neglect, or exploitation pursuant to § 7-1903 shall be immune from civil or criminal liability for so reporting if he, she, or it has acted in good faith." This immunity covers the act of reporting and reasonable cooperation with the investigation.

8.3. Confidentiality acknowledgment. I understand that records concerning this report are confidential under D.C. Code § 7-1909 and may be disclosed only as authorized by statute.

8.4. No retaliation. I understand that retaliation against a reporter is prohibited and may give rise to additional civil and criminal liability.

[________________________________] Date: [__/__/____]
[REPORTER SIGNATURE]

9. SUBMISSION CHANNELS AND CONFIDENTIALITY

9.1. Primary channel — APS Hotline (oral report). Call (202) 541-3950, 24 hours a day, 7 days a week.

9.2. Written report. Submit a copy of this completed form to:

• DC Department of Human Services
• Adult Protective Services Division
• 64 New York Avenue NE, 6th Floor, Washington, DC 20002
• Fax: [VERIFY CURRENT FAX] ; Secure email: [VERIFY CURRENT EMAIL]

9.3. Cross-reports. If the adult resides in a licensed long-term-care facility, also notify the Office of the DC Long-Term Care Ombudsman at (202) 434-2190 and DC Health Health Regulation and Licensing Administration at (202) 442-5833.

9.4. Law-enforcement cross-report. Where the alleged conduct is criminal (assault, sexual abuse, theft, fraud, financial exploitation), call MPD at 911 (emergency) or 311 (non-emergency) and request an incident-report number.

9.5. Confidentiality. This form, the underlying report, and all documents collected during the APS investigation are confidential under D.C. Code § 7-1909 and must be handled accordingly.

10. DC PRACTICE NOTES

• Reporting deadline. D.C. Code § 7-1903 requires "immediate" reporting upon forming substantial cause to believe protective services are needed. The statute has no fixed hour count — practitioners should treat this as same-day, before leaving the encounter when feasible.
• Self-neglect. Since the 2006 amendment carried forward by D.C. Law 21-199 (2016), self-neglect is squarely within the reporting and investigation scope. Cognitive-impairment indicators (Section 3) should be documented.
• Mandatory categories. The mandatory-reporter list is closed; non-listed professionals (e.g., teachers, clergy, attorneys representing the alleged perpetrator) are encouraged but not required to report. Attorneys representing the adult should consult Rule 1.6 and Rule 1.14 of the DC Rules of Professional Conduct before reporting.
• Penalties. D.C. Code § 7-1912 imposes fines up to $300 for a knowing failure to report by a mandatory reporter; professional-license discipline may follow.
• No retaliation against employees. Employers may not retaliate against an employee for making a good-faith APS report. Document any retaliation contemporaneously.
• Coordination with criminal process. APS investigations and police investigations may proceed in parallel. Preserve evidence (photographs, statements, records) at first contact.
• Capacity and consent. APS may not impose protective services on an adult with decisional capacity who refuses them, except where the adult is found to lack capacity by court order or where emergency intervention is warranted under D.C. Code § 7-1905.

11. SOURCES AND REFERENCES

• D.C. Code Title 7, Chapter 19 (Adult Protective Services) — https://code.dccouncil.gov/us/dc/council/code/titles/7/chapters/19
• D.C. Code § 7-1903 (Reporting requirements) — https://code.dccouncil.gov/us/dc/council/code/sections/7-1903
• D.C. Code § 7-1908 (Immunity)
• D.C. Code § 7-1912 (Penalties)
• D.C. Law 21-199, Adult Protective Services Amendment Act of 2016 — https://code.dccouncil.gov/us/dc/council/laws/21-199
• DC Department of Human Services — APS Mandatory Reporter Page — https://dhs.dc.gov/service/adult-protective-services-mandatory-reporters
• DC Department of Aging and Community Living — Adult Protective Services — https://dacl.dc.gov/service/adult-protective-services-0
• DC APS Mandatory Reporters Brochure — https://disb.dc.gov/sites/default/files/dc/sites/disb/publication/attachments/Mandatory%20Reporters%20Brochure.pdf
• DC APS Hotline: (202) 541-3950 (24/7)
• Office of the DC Long-Term Care Ombudsman: (202) 434-2190
• DC Health Health Regulation and Licensing Administration: (202) 442-5833
• US Department of Justice Elder Justice Initiative — https://www.justice.gov/elderjustice

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Always call the APS Hotline immediately and confirm current submission channels with DHS APS before transmitting written records. An attorney licensed in the District of Columbia must review and customize this form before relying on it in any contested matter.