Iowa Dependent Adult Abuse / Adult Protective Services Report

IOWA DEPENDENT ADULT ABUSE / ADULT PROTECTIVE SERVICES REPORT

TABLE OF CONTENTS

1. Hotline Contact and Acknowledgement
2. Reporter Information
3. Reporter Status
4. Dependent Adult (Alleged Victim) Information
5. Alleged Perpetrator Information
6. Type of Abuse Alleged
7. Narrative of Suspected Abuse
8. Indicators and Evidence
9. Imminent Danger / Safety Assessment
10. Other Agencies and Persons Notified
11. Confidentiality and Immunity
12. Reporter Verification
13. Iowa Practice Notes
14. Sources and References

1. HOTLINE CONTACT AND ACKNOWLEDGEMENT

I, the undersigned reporter, telephoned the Iowa HHS Dependent Adult Abuse Hotline within twenty-four (24) hours of forming a reasonable belief that the dependent adult identified below has suffered abuse, as required by Iowa Code § 235B.3. This written form is submitted as a supplemental record only.

[________________________________]

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

2. REPORTER INFORMATION

3. REPORTER STATUS

• ☐ Mandatory reporter under Iowa Code § 235B.3(2). I am a person who, in the scope of my employment or profession, examines, attends, counsels, or treats a dependent adult, including (check applicable category):
• ☐ Health practitioner (physician, dentist, optometrist, podiatrist, chiropractor, intern, resident, physical therapist, occupational therapist, physician assistant)
• ☐ Registered nurse, licensed practical nurse, advanced registered nurse practitioner, nurse aide, certified medication aide
• ☐ Psychologist, mental health professional, social worker, marital and family therapist, counselor
• ☐ Pharmacist
• ☐ Employee or operator of a public or private health-care facility, hospital, assisted living, RCF, ICF, ICF/ID, nursing facility, hospice
• ☐ Employee of a HCBS waiver provider, adult day services program, or PACE program
• ☐ Peace officer
• ☐ Member of the clergy (subject to clergy-penitent privilege exception in § 235B.3(3))
• ☐ Employee or operator of a financial institution (financial-exploitation reporting)
• ☐ Other: [________________________________]
• ☐ Permissive reporter under Iowa Code § 235B.3(1). I am a person who reasonably believes a dependent adult has suffered abuse but am not within the mandatory categories listed above.

4. DEPENDENT ADULT (ALLEGED VICTIM) INFORMATION

Dependent adult status (Iowa Code § 235B.1(4)). The above-named individual is age 18 or older and, due to a mental or physical condition, is unable to protect his or her own interests or unable to perform or obtain services necessary to meet essential human needs without assistance from another. Basis for this determination:

[____________________________________________________________]

5. ALLEGED PERPETRATOR INFORMATION

(Complete one block per alleged perpetrator. Attach additional sheets if needed.)

6. TYPE OF ABUSE ALLEGED

Check all that apply. Iowa Code § 235B.1(5) defines "dependent adult abuse" to include the following categories:

• ☐ Physical injury (bruising, lacerations, fractures, burns, restraint marks)
• ☐ Unreasonable confinement or punishment (locked rooms, withholding mobility aids)
• ☐ Sexual abuse / sexual exploitation (Iowa Code Chapter 709 offenses)
• ☐ Denial of critical care (food, water, clothing, shelter, hygiene, supervision, prescribed medication, medical care)
• ☐ Neglect by caretaker (failure to act when assumed responsibility)
• ☐ Self-neglect (Iowa Code § 235B.1(5)(b)(2))
• ☐ Exploitation — wrongful, deceptive, or unauthorized taking, retention, or use of property, benefits, or resources of the dependent adult (financial exploitation, undue influence, coerced transfers, predatory POA abuse)
• ☐ Personal degradation (verbal, emotional, psychological abuse including degrading photographs / video posted on social media — § 235B.1(5)(a)(7))
• ☐ Other (specify): [________________________________]

7. NARRATIVE OF SUSPECTED ABUSE

Provide a chronological, fact-based narrative. Use direct quotes when possible. Avoid conclusions; report observations.

Date(s) of incident(s): [__/__/____] to [__/__/____]

Location(s): [________________________________]

Witnesses: [________________________________]

What the reporter personally observed:

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

What the dependent adult disclosed (verbatim where possible):

[____________________________________________________________]

[____________________________________________________________]

What others told the reporter (and who said it):

[____________________________________________________________]

[____________________________________________________________]

Pattern, frequency, escalation:

[____________________________________________________________]

Prior reports / investigations known to reporter:

[____________________________________________________________]

8. INDICATORS AND EVIDENCE

9. IMMINENT DANGER / SAFETY ASSESSMENT

• ☐ Imminent danger of death or serious injury — 911 contacted. Briefly describe: [________________________________]
• ☐ Significant risk but not imminent. Concerns: [________________________________]
• ☐ No immediate physical danger but ongoing concern (e.g., financial exploitation, neglect).
• ☐ Dependent adult requires medical attention now: ☐ Yes ☐ No
• ☐ Dependent adult requires shelter / removal: ☐ Yes ☐ No
• ☐ Emergency Elder Abuse Protective Order considered under Iowa Code Chapter 235F: ☐ Yes ☐ No

10. OTHER AGENCIES AND PERSONS NOTIFIED

11. CONFIDENTIALITY AND IMMUNITY

• Immunity (Iowa Code § 235B.3(11)). A person making a report or assisting in an investigation in good faith is immune from civil and criminal liability that might otherwise be incurred. The immunity does not extend to reports made in bad faith or with malice.
• Confidentiality (Iowa Code §§ 235B.6, 235B.8 and 235B.9). The identity of the reporter and the contents of the report are confidential, subject to disclosure only as authorized by statute (e.g., to law enforcement, prosecutors, the dependent adult's attorney or guardian ad litem, the Department, court order).
• No retaliation. Employers may not discharge, demote, or otherwise retaliate against an employee for making a good-faith report.
• False reports. Knowingly making a false report is a simple misdemeanor under Iowa Code § 235B.3(13) and may give rise to civil liability.

12. REPORTER VERIFICATION

I declare under penalty of perjury under Iowa law that the foregoing report is true and correct to the best of my knowledge, and that I have made the report in good faith based on a reasonable belief that the dependent adult identified herein has suffered or is at risk of dependent adult abuse.

Date: [__/__/____]

[________________________________]

[REPORTER NAME]

[________________________________]

[REPORTER TITLE / EMPLOYER]

(Optional — for non-mandatory reporters who request to remain anonymous, leave the signature line blank. Mandatory reporters must identify themselves under Iowa Code § 235B.3(7).)

13. IOWA PRACTICE NOTES

• 24-hour clock starts at suspicion. The duty to report is triggered the moment a mandatory reporter forms a "reasonable belief" — not when the reporter has confirmed abuse. Waiting for confirmation is itself a violation of § 235B.3.
• Personal versus institutional reporting. A facility's internal incident-reporting procedure does NOT replace the individual reporter's duty to call HHS. Both must occur.
• Facility-based abuse routing. When the alleged abuser is a credentialed health-care worker or facility employee, jurisdiction may shift to DIAL Health Facilities Division under Iowa Code Chapter 235E. Reporters can call BOTH the IA HHS hotline and the DIAL hotline; agencies coordinate.
• Dependent Adult Abuse Information Registry. Substantiated findings under Iowa Code § 235B.5 are entered into a confidential registry used for employment screening (caregiver, school, child-care, dependent-adult positions). A respondent has the right to a contested-case appeal under Iowa Code Chapter 17A.
• Privilege and clergy. Iowa Code § 235B.3(3) abrogates most professional privileges (medical, mental health, social worker, attorney, accountant) for purposes of reporting, with a narrow exception for confidential communications between attorney and client and for clergy-penitent communications protected under § 622.10.
• Financial institutions. Iowa law (Iowa Code § 235B.20 et seq. — read with current code) authorizes financial institutions to delay transactions where suspected exploitation is identified and to make permissive APS reports.
• Self-neglect. Iowa recognizes self-neglect as a reportable category. APS engagement is voluntary for capable adults; involuntary intervention may require petition under Iowa Code Chapter 229 (mental-health commitment) or Chapter 633 (guardianship/conservatorship).
• Statute of limitations for civil claims. Civil actions arising from elder abuse follow general tort limitations periods (typically 2 years for personal injury under Iowa Code § 614.1(2); 5 years for fraud / written contract; toll for incapacity per § 614.8). Verify before filing.
• Training requirements. Every two hours of approved training within six months of initial employment, then renewed every three years (§ 235B.16). Document training in the personnel file.

14. SOURCES AND REFERENCES

• Iowa HHS — Dependent Adult Abuse / Adult Protective Services: https://hhs.iowa.gov/family-community/adult-protective-services
• Iowa HHS — Dependent Adult Abuse Reporting (24/7 Hotline 1-800-362-2178): https://hhs.iowa.gov/contacts/dependent-adult-abuse-reporting
• Iowa HHS — Mandatory Reporters: https://hhs.iowa.gov/report-abuse-fraud/mandatory-reporters
• Iowa Code Chapter 235B (Dependent Adult Abuse Services — Information Registry): https://www.legis.iowa.gov/docs/ico/chapter/235B.pdf
• Iowa Code § 235B.3 (Reporting): https://www.legis.iowa.gov/docs/code/235B.3.pdf
• Iowa Code Chapter 235E (Dependent Adult Abuse — Facility-based)
• Iowa Code Chapter 235F (Elder Abuse Protective Order)
• Iowa Admin. Code r. 441—176 and r. 441—177
• Iowa Attorney General — Older Iowans / Report Elder Abuse: https://www.iowaattorneygeneral.gov/for-consumers/for-older-iowans/reportelderabuse
• DIAL — File a Complaint (facility-based): https://dial.iowa.gov/i-need/complaints
• Mandatory Reporter Training (DIAL): https://dial.iowa.gov/i-need/report/mandatory-reporter-training
• Iowa HHS Form 470-2441 — Suspected Dependent Adult Abuse Report
• Federal Elder Justice Act, 42 U.S.C. § 1397j et seq.

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Mandatory reporters must telephone the Iowa HHS Dependent Adult Abuse Hotline at 1-800-362-2178 within 24 hours of forming a reasonable belief; do not delay the oral report to complete this written form. An Iowa-licensed attorney should review this report before submission in legally sensitive matters.