Georgia Adult Protective Services Report — Disabled Adult / Elder Person Abuse, Neglect, or Exploitation

REPORT OF SUSPECTED ABUSE, NEGLECT, OR EXPLOITATION OF A DISABLED ADULT OR ELDER PERSON — STATE OF GEORGIA

TABLE OF CONTENTS

1. Reporter Information
2. Mandated Reporter Status
3. Alleged Victim Information
4. Alleged Perpetrator(s)
5. Nature of Abuse, Neglect, or Exploitation
6. Factual Basis / Reasonable Cause
7. Witnesses and Other Knowledgeable Persons
8. Immediate Risk Assessment
9. Prior Reports and Concurrent Filings
10. Privileged Communications and Immunity
11. Submission and Verification
12. Georgia Practice Notes
13. Sources and References

1. REPORTER INFORMATION

Method of report (check all used):

☐ Telephone to APS Central Intake at 1-866-552-4464 (option 3)

☐ Online portal — Georgia DHS Division of Aging Services / APS

☐ Written report delivered by ☐ U.S. Mail ☐ Hand delivery ☐ Email ☐ Fax to [__________]

☐ Concurrent report to local law enforcement at [AGENCY]

☐ Concurrent report to local district attorney at [OFFICE]

2. MANDATED REPORTER STATUS

The reporter is (check all that apply):

☐ A mandated reporter under O.C.G.A. § 30-5-4(a)(1.1) — specifically a:

☐ Person required to report child abuse under O.C.G.A. § 19-7-5

☐ Physician, osteopath, intern, or resident

☐ Hospital or medical personnel

☐ Dentist, dental hygienist

☐ Psychologist, marriage and family therapist, professional counselor, or social worker

☐ Nurse (RN, LPN, advanced practice)

☐ Physical therapist, occupational therapist

☐ Day-care personnel

☐ Coroner or medical examiner

☐ Emergency medical services personnel (EMT, cardiac technician, paramedic, first responder)

☐ Employee of a public or private agency engaged in professional health-related services to elder persons or disabled adults

☐ Law enforcement officer

☐ Employee of a financial institution or investment company (exploitation only) — O.C.G.A. § 30-5-4(a)(1.1)(M)

☐ Clergy member (subject to confessional privilege exception)

☐ The reporter is NOT a mandated reporter but reports voluntarily under O.C.G.A. § 30-5-4(b).

3. ALLEGED VICTIM INFORMATION

Statutory category (check at least one):

☐ Elder person — 65 years of age or older (O.C.G.A. § 30-5-3(7.1))

☐ Disabled adult — 18 years or older with a mental or physical incapacity affecting ability to provide adequately for own care or protection (O.C.G.A. § 30-5-3(2))

Capacity / cognition:

☐ Diagnosed dementia or cognitive impairment — diagnosis: [__________]

☐ Physical impairment / mobility limitation — describe: [__________]

☐ Mental health diagnosis — describe: [__________]

☐ Appears to lack capacity to consent to or refuse protective services

☐ Appears to have capacity; report made because abuse / neglect / exploitation continues despite victim's awareness

Caretaker / fiduciary information:

4. ALLEGED PERPETRATOR(S)

5. NATURE OF ABUSE, NEGLECT, OR EXPLOITATION

(Check all that apply.)

Abuse — O.C.G.A. § 30-5-3(1):

☐ Physical abuse — striking, restraining, sexual battery, infliction of pain or injury

☐ Emotional / psychological abuse — threats, intimidation, harassment, isolation

☐ Sexual abuse / sexual battery

☐ Use of physical or chemical restraint not authorized by a physician

Neglect — O.C.G.A. § 30-5-3(8):

☐ Failure of caretaker to provide food, clothing, shelter

☐ Failure to provide medical care, supervision, or essential services

☐ Self-neglect — victim unable to provide for own care

☐ Abandonment

☐ Unsafe living conditions (hoarding, no utilities, infestation)

Exploitation — O.C.G.A. § 30-5-3(7) and § 16-5-102:

☐ Misuse of funds / property by caretaker, agent, or fiduciary

☐ Theft, fraud, undue influence, or duress

☐ Forged checks or unauthorized account withdrawals

☐ Suspicious changes to deed, will, beneficiary designation, or POA

☐ Predatory loans, scams, identity theft

☐ Coercion to sign documents

6. FACTUAL BASIS / REASONABLE CAUSE

The reporter has reasonable cause to believe that the named victim has been abused, neglected, or exploited based on the following observations and information:

Date(s) of incident or observation: [__/__/____] through [__/__/____]

Location(s): [________________________________]

Detailed factual narrative:

[NARRATIVE — Provide a chronological description of observed conditions, statements made by the victim, statements made by the perpetrator, financial irregularities reviewed, photographs taken, medical findings, and any other facts establishing reasonable cause. Use additional pages as necessary.]

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

Documentary evidence attached or available:

☐ Photographs of injuries, bruising, pressure ulcers, or living conditions

☐ Medical records / discharge summary / ER notes

☐ Bank or brokerage statements showing suspicious transactions

☐ Copies of checks, ATM receipts, wire transfer records

☐ Power of Attorney, will, or deed evidencing recent change

☐ Text messages, voicemails, emails

☐ Body cam / surveillance video

☐ Other: [__________]

7. WITNESSES AND OTHER KNOWLEDGEABLE PERSONS

8. IMMEDIATE RISK ASSESSMENT

The reporter assesses the following level of immediate risk:

☐ Imminent danger of serious physical harm or death — call 911 contemporaneously with this report

☐ High risk — perpetrator has continuing access; protective services needed within 24 hours

☐ Moderate risk — risk present but not imminent; APS investigation requested

☐ Lower risk / financial only — exploitation has occurred but no physical danger; investigation requested

Has 911 / emergency services been contacted? ☐ Yes — agency: [__________], time: [____] ☐ No

Does victim require immediate emergency placement? ☐ Yes ☐ No

Is a Temporary Protective Order or emergency guardianship indicated? ☐ Yes (consider O.C.G.A. § 30-5-5 emergency protective services and O.C.G.A. § 29-4-14 emergency guardianship petition) ☐ No

9. PRIOR REPORTS AND CONCURRENT FILINGS

☐ Prior APS report(s) — date(s): [__/__/____], intake number(s): [__________]

☐ Concurrent report to law enforcement — agency: [__________], report no.: [__________]

☐ Concurrent report to Long-Term Care Ombudsman — case no.: [__________]

☐ Concurrent report to DCH Healthcare Facility Regulation Division — complaint no.: [__________]

☐ Concurrent report to financial institution fraud / SAR filed

☐ Civil litigation pending — court / case no.: [__________]

☐ Probate / guardianship action pending — court / case no.: [__________]

10. PRIVILEGED COMMUNICATIONS AND IMMUNITY

The reporter acknowledges and asserts:

• Pursuant to O.C.G.A. § 30-5-4(c), the reporting obligation overrides any otherwise-applicable privilege, including physician-patient and psychotherapist-patient privilege, except as to communications confided to clergy in the context of confession or similar confidential church discipline.
• Pursuant to O.C.G.A. § 30-5-4(d), any person, official, or institution participating in good faith in the making of a report, the transmittal of a report, or any investigative or judicial proceedings under the Disabled Adults and Elder Persons Protection Act is immune from any civil or criminal liability that might otherwise be incurred or imposed.
• Pursuant to O.C.G.A. § 30-5-8, willful failure to report by a mandated reporter is a misdemeanor.

11. SUBMISSION AND VERIFICATION

I certify under penalty of perjury that I have read the foregoing report and that the statements of fact contained herein are true and correct to the best of my knowledge, information, and belief, and that this report is made in good faith pursuant to O.C.G.A. § 30-5-4.

[________________________________]

[REPORTER NAME]

Title: [__________]

Date: [__/__/____]

Submission addresses:

• APS Central Intake (telephone): 1-866-552-4464 (option 3); 24-hour toll-free statewide
• Online: Georgia DHS Division of Aging Services — APS reporting portal at https://aging.georgia.gov/report-elder-abuse-neglect-or-exploitation/adult-protective-services-aps
• Mail (written report): Georgia Department of Human Services, Division of Aging Services, Adult Protective Services, 2 Peachtree Street NW, Atlanta, GA 30303
• Local law enforcement: [AGENCY ADDRESS / PHONE]
• If victim resides in a long-term care facility: report instead to the State Long-Term Care Ombudsman at 1-866-552-4464 (option 5) and to the DCH Healthcare Facility Regulation Division complaint intake at 1-800-878-6442 or 404-657-5726.

12. GEORGIA PRACTICE NOTES

• Statutory framework. The Georgia Disabled Adults and Elder Persons Protection Act, O.C.G.A. § 30-5-1 et seq., enacted to protect persons 65+ and disabled adults 18+, establishes mandated reporting, immunity, APS investigative authority, and emergency protective service mechanisms.
• APS jurisdiction. Georgia APS, within the DHS Division of Aging Services, investigates non-institutional cases — community-dwelling victims, including those in private homes and unlicensed care arrangements. Long-term care facility cases are handled by DCH Healthcare Facility Regulation Division and the Long-Term Care Ombudsman.
• Reporting standard. "Reasonable cause to believe" — not certainty. Witnesses observing isolated, ambiguous, or circumstantial indicators must still report when the totality suggests abuse, neglect, or exploitation.
• Time to report. O.C.G.A. § 30-5-4(b) does not impose a fixed numeric deadline (unlike some states' 24- or 48-hour rules), but requires reporting "as soon as practicable" — reporters should make the oral report immediately and follow with a written report within 24 hours, as is the recognized professional standard. The DAS APS Manual treats imminent-risk intakes as same-day priority.
• Mandated reporters and financial institutions. O.C.G.A. § 30-5-4(a)(1.1)(M) extends the reporting duty to bank, credit union, and investment-company employees who have reasonable cause to believe a disabled adult or elder person has been exploited, with limited exceptions for fiduciary capacity.
• Immunity. O.C.G.A. § 30-5-4(d) provides broad civil and criminal immunity to good-faith reporters, including those who participate in investigations or proceedings.
• Penalty for failure to report. Willful failure to report by a mandated reporter is a misdemeanor under O.C.G.A. § 30-5-8.
• Confidentiality. Reports and identifying information about reporters are confidential under O.C.G.A. § 30-5-7 and shall be released only as authorized by law.
• Concurrent civil remedies. Reporting does not preclude — and often supports — concurrent civil remedies including emergency guardianship (O.C.G.A. § 29-4-14), emergency conservatorship (O.C.G.A. § 29-5-14), TPO (O.C.G.A. § 19-13-3, where applicable to family violence), elder-exploitation civil action (O.C.G.A. § 30-5-9), and recovery for exploitation under § 16-5-102.
• Criminal referral. Where the conduct constitutes a crime — battery on an elder person (§ 16-5-100), exploitation of a disabled adult or elder person (§ 16-5-102), or theft — concurrent referral to the local police, sheriff, and district attorney is best practice.

13. SOURCES AND REFERENCES

• Georgia DHS Division of Aging Services — Adult Protective Services: https://aging.georgia.gov/report-elder-abuse-neglect-or-exploitation/adult-protective-services-aps
• Georgia DHS APS — main page: https://dhs.georgia.gov/adult-protective-services
• Report Elder Abuse — Georgia.gov: https://georgia.gov/report-elder-abuse
• O.C.G.A. § 30-5-4 (Reporting): https://law.justia.com/codes/georgia/title-30/chapter-5/section-30-5-4/
• O.C.G.A. § 30-5-1 et seq. (Disabled Adults and Elder Persons Protection Act): https://law.justia.com/codes/georgia/title-30/chapter-5/
• DAS APS Policy Manual (PAMMS 5500): https://pamms.dhs.ga.gov/das/aps/5500/
• O.C.G.A. § 16-5-100 to § 16-5-102 (Crimes against elder persons / disabled adults)
• DHS Quick Reference Numbers: https://dhs.georgia.gov/sites/dhs.georgia.gov/files/DHS%20Quick%20Reference%20Numbers.pdf
• Georgia Long-Term Care Ombudsman: https://www.georgiaombudsman.org

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Reporters should verify the current APS hotline (1-866-552-4464) and any updated DAS reporting protocols at https://aging.georgia.gov before submission. An attorney licensed in Georgia must review and customize this template for use in litigation, proceedings, or systemic-abuse cases.