Indiana Adult Protective Services Report — Endangered Adult

INDIANA ADULT PROTECTIVE SERVICES (APS) REPORT — ENDANGERED ADULT

TABLE OF CONTENTS

1. Emergency Triage
2. Reporter Information
3. Endangered Adult Information
4. Alleged Perpetrator(s)
5. Nature of Abuse, Neglect, Battery, or Exploitation
6. Specific Incident Description
7. Pattern, Prior Incidents, and Witnesses
8. Capacity, Decision-Making, and Vulnerability Factors
9. Financial Exploitation Specifics
10. Reporter Acknowledgments and Signature
11. Statutory Reference Sheet
12. Indiana Practice Notes
13. Sources and References

1. EMERGENCY TRIAGE

Before completing this form, confirm whether the adult is in immediate danger:

• ☐ Adult is in immediate danger of death or serious bodily injury — call 911 NOW
• ☐ Adult is not in immediate danger; APS report is appropriate
• ☐ Concurrent law-enforcement report needed (e.g., assault, battery, theft, fraud)
• ☐ Concurrent ISDH / facility complaint needed (resident of nursing facility / residential care / assisted living — see separate Long-Term Care Ombudsman Complaint template)

Date and time of this report: [__/__/____] at [__:__] ☐ a.m. ☐ p.m.

Method of report (check all that apply):

• ☐ APS Hotline 1-800-992-6978 — call confirmation #: [________________________________]
• ☐ APS Online portal — submission ID: [________________________________]
• ☐ Local APS unit / [COUNTY] Prosecutor's Office — intake worker: [________________________________]
• ☐ Local law enforcement — agency: [________________________________], report #: [________________________________]
• ☐ Written supplement only (this form)

2. REPORTER INFORMATION

3. ENDANGERED ADULT INFORMATION

Endangered-adult criteria (Ind. Code § 12-10-3-2). Mark each that applies:

• ☐ Individual is at least 18 years of age
• ☐ Individual is incapable, by reason of mental illness, intellectual disability, dementia, habitual drunkenness, excessive use of drugs, or other physical or mental incapacity, of managing or directing the management of the individual's property
• ☐ Individual is incapable of providing or directing the provision of self-care
• ☐ Individual is harmed or threatened with harm as a result of:
• ☐ Neglect
• ☐ Battery
• ☐ Exploitation of the individual's personal services or property

4. ALLEGED PERPETRATOR(S)

If unknown, mark "Unknown" and provide all available identifying detail.

5. NATURE OF ABUSE, NEGLECT, BATTERY, OR EXPLOITATION

Check all that apply (Ind. Code § 12-10-3-3):

• ☐ Neglect — failure to provide food, shelter, clothing, medical care, or supervision necessary to maintain physical or mental health
• ☐ Self-neglect — adult unable or unwilling to perform essential self-care
• ☐ Battery / physical abuse — knowing or intentional touching in a rude, insolent, or angry manner; bodily injury; bruises, fractures, burns, restraint marks
• ☐ Sexual abuse — non-consensual sexual contact or contact with an adult lacking capacity to consent
• ☐ Emotional / psychological abuse — threats, intimidation, isolation, humiliation, or harassment
• ☐ Financial exploitation — wrongful taking, withholding, or appropriation of funds, benefits, property, or personal services
• ☐ Caregiver neglect — paid or unpaid caregiver fails in duty of care
• ☐ Abandonment — desertion by a person responsible for care
• ☐ Medication misuse / overmedication / chemical restraint
• ☐ Dangerous environmental conditions (filth, vermin, lack of utilities, unsafe structure)
• ☐ Other: [________________________________]

6. SPECIFIC INCIDENT DESCRIPTION

Provide a detailed, fact-based narrative. Use additional pages if needed.

Date(s) of alleged conduct: [__/__/____] through [__/__/____]

Location: [________________________________]

What did you observe, hear, or learn (state facts, not conclusions):

[________________________________]

[________________________________]

[________________________________]

[________________________________]

Visible injuries / observable signs (describe):

Statements made by the endangered adult (verbatim where possible):

[________________________________]

[________________________________]

Statements made by the alleged perpetrator (verbatim where possible):

[________________________________]

Physical or documentary evidence (and chain of custody):

7. PATTERN, PRIOR INCIDENTS, AND WITNESSES

Prior incidents observed or reported (chronological):

Other witnesses:

8. CAPACITY, DECISION-MAKING, AND VULNERABILITY FACTORS

9. FINANCIAL EXPLOITATION SPECIFICS

Complete only if Section 5 indicates financial exploitation.

10. REPORTER ACKNOWLEDGMENTS AND SIGNATURE

I, [REPORTER NAME], affirm under penalty of perjury under Indiana law that:

1. I have reason to believe the individual identified in Section 3 is an endangered adult within the meaning of Ind. Code § 12-10-3-2;
2. The information contained in this report is true and complete to the best of my knowledge, information, and belief;
3. I make this report in good faith pursuant to my duty under Ind. Code § 12-10-3-9 and rely on the immunity provided by Ind. Code § 12-10-3-11 and Ind. Code § 34-30-2-40;
4. I understand that knowing failure to report constitutes a Class B misdemeanor under Ind. Code § 12-10-3-22; and
5. I understand that this report and my identity as reporter are confidential under Ind. Code § 12-10-3-12 and may be disclosed only by court order or written consent.

Reporter signature: [________________________________]

Print name: [________________________________]

Date: [__/__/____]

If institutional reporter, supervisor signature: [________________________________]

Title: [________________________________]

Date: [__/__/____]

11. STATUTORY REFERENCE SHEET

Endangered Adult — Ind. Code § 12-10-3-2. An individual who is at least 18, incapable by reason of mental illness, intellectual disability, dementia, habitual drunkenness, drug abuse, or other physical or mental incapacity of managing property or providing self-care, and who is harmed or threatened with harm by neglect, battery, or exploitation.

Duty to Report — Ind. Code § 12-10-3-9. "An individual who believes or has reason to believe that another individual is an endangered adult shall make a report under this chapter."

Communication and Contents — Ind. Code § 12-10-3-10. Reports may be made orally or in writing to the division (FSSA), the APS unit, or a law-enforcement agency. Reports should include the name and address of the endangered adult, name and address of any caregiver, the nature of the harm, and other identifying information.

Immunity — Ind. Code § 12-10-3-11; Ind. Code § 34-30-2-40. A person, other than a person against whom a complaint has been made, who in good faith makes a required report; testifies or participates in any investigation, administrative, or judicial proceeding; takes or causes photographs or x-rays of an endangered adult; or discusses such a report with the division, an APS unit, a law-enforcement agency, or other appropriate agency, is immune from civil and criminal liability arising from those actions.

Confidentiality — Ind. Code § 12-10-3-12. All records and reports concerning endangered adults are confidential and may be disclosed only as provided by statute or court order.

Failure to Report — Ind. Code § 12-10-3-22. A person who knowingly fails to make a required report commits a Class B misdemeanor.

Criminal Statutes — Ind. Code §§ 35-46-1-12 (Exploitation of an endangered adult), 35-46-1-13 (Battery / neglect of an endangered adult). Provide the criminal counterparts to APS findings; APS frequently refers cases for criminal prosecution.

12. INDIANA PRACTICE NOTES

• Universal mandatory reporting. Indiana imposes the duty to report on every person, not merely on enumerated professionals. There is no permissive-reporting alternative; once a person has "reason to believe" an adult is endangered, the duty to report attaches.
• State hotline. The statewide APS hotline 1-800-992-6978 is operated by FSSA in conjunction with the regional APS hub units. Online reports are accepted at the FSSA APS Online Report portal. Either route satisfies the statutory duty.
• Regional hub structure. Indiana APS operates through hub offices housed in selected county prosecutors' offices, each covering a multi-county region. The regional hub receives the report from the FSSA intake unit and coordinates the in-person investigation and any criminal referral.
• Response timing. APS regulations and FSSA practice contemplate prompt face-to-face contact: within 24 hours for life-threatening reports and within longer windows for non-emergency cases. Confirm current guidance through the local hub.
• Self-determination. A capable adult may refuse APS services. Where the adult lacks capacity, APS may petition for emergency or permanent guardianship under Ind. Code § 29-3.
• Long-term-care facilities. Reports involving residents of nursing facilities, residential care, or assisted living should also be filed with the Indiana Long-Term Care Ombudsman Program (1-800-622-4484) and the Indiana Department of Health Complaints Division (1-800-246-8909). Use the companion Nursing Home Resident Complaint template.
• Concurrent law-enforcement referral. Where the conduct is criminal (battery, theft, fraud, sexual assault, exploitation), report concurrently to local law enforcement. APS will coordinate referral to the regional prosecutor for criminal evaluation under Ind. Code §§ 35-46-1-12, -13.
• Financial-institution reporting. Banks, credit unions, and securities firms have parallel reporting tools under federal SAR / FinCEN Advisory FIN-2022-A002 and Indiana Securities Division authority (Ind. Code § 23-19-6-9.5). A financial-institution APS report is in addition to any internal SAR.
• Documentation discipline. Contemporaneously document observations, statements, photographs, and chain of custody. APS investigations and any subsequent criminal prosecution will rely heavily on the reporter's contemporaneous notes.
• Immunity is not absolute. Immunity protects good-faith reports and participation. A report made with malice or knowledge of falsity is outside the immunity provision; conversely, mistaken belief, where reasonable, is protected.

13. SOURCES AND REFERENCES

• Indiana Adult Protective Services (FSSA Division of Aging) — https://www.in.gov/fssa/da/adult-protective-services/
• APS Online Report — https://aps-govcloud.my.site.com/APSOnlineReport/s/
• Indiana Prosecuting Attorneys Council (APS Hub Coordination) — https://www.in.gov/ipac/adult-protective-services/
• Ind. Code § 12-10-3 (Adult Protective Services) — http://iga.in.gov/legislative/laws/
• Ind. Code §§ 35-46-1-12, 35-46-1-13 (Endangered-adult crimes)
• Ind. Code § 34-30-2-40 (Civil immunity — endangered-adult report)
• 455 IAC 2 (FSSA Adult Protective Services rules)
• Indiana Long-Term Care Ombudsman — 1-800-622-4484; https://www.in.gov/ombudsman/long-term-care-ombudsman/
• Indiana State Department of Health Complaints — 1-800-246-8909; https://www.in.gov/health/
• FinCEN Advisory FIN-2022-A002 (Elder Financial Exploitation)
• National Center on Elder Abuse — https://ncea.acl.gov/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. If a person is in immediate danger, call 911. Indiana imposes a universal duty to report endangered adults; a knowing failure to report is a Class B misdemeanor. Counsel licensed in Indiana should review institutional reporting protocols and any concurrent civil or criminal proceedings.