Kansas Adult Protective Services Report — Abuse, Neglect, or Financial Exploitation of Certain Adults

KANSAS ADULT PROTECTIVE SERVICES REPORT

TABLE OF CONTENTS

1. Reporter Information
2. Reporting Track and Statutory Basis
3. Vulnerable Adult Information
4. Alleged Perpetrator(s)
5. Nature of Abuse, Neglect, or Exploitation
6. Factual Narrative
7. Witnesses and Other Knowledge
8. Immediate Risk Assessment
9. Prior Reports and Agency Contacts
10. Mandatory Reporter Certification
11. Submission Instructions
12. Kansas Practice Notes
13. Sources and References

1. REPORTER INFORMATION

1.1. Reporter Name: [________________________________]

1.2. Title / Profession: [________________________________]

1.3. Employer / Agency: [________________________________]

1.4. License Number (if applicable): [________________________________]

1.5. Mailing Address: [________________________________]

1.6. Telephone: [________________________________]

1.7. Email: [________________________________]

1.8. Date / Time of Report: [__/__/____] at [____]:[____] ☐ a.m. ☐ p.m.

1.9. Date / Time of First Knowledge: [__/__/____] at [____]:[____] ☐ a.m. ☐ p.m.

1.10. Reporter Status:

• ☐ Mandatory reporter under K.S.A. § 39-1431 (community track)
• ☐ Mandatory reporter under K.S.A. § 39-1402 (adult care home / institutional track)
• ☐ Permissive reporter (any person)
• ☐ Anonymous (note: anonymity is permitted; mandatory reporters typically must identify themselves)

2. REPORTING TRACK AND STATUTORY BASIS

The Reporter submits this report under (check all that apply):

• ☐ K.S.A. § 39-1430 et seq. — Community Track (DCF APS). Vulnerable adult resides in own home, family member's home, friend's home, or adult family home. Primary intake: DCF Adult Protective Services via the Kansas Protection Report Center (1-800-922-5330).

• ☐ K.S.A. § 39-1401 et seq. — Institutional Track (KDHE / KDADS). Vulnerable adult is a resident of an adult care home, nursing facility, assisted living, home plus, residential health care facility, hospital, state institution, or other regulated long-term care setting. Primary intake: KDADS Complaint Hotline (1-800-842-0078) and/or KDHE; cross-report to law enforcement.

• ☐ Concurrent report to law enforcement for suspected criminal conduct (K.S.A. § 21-5417 — mistreatment of a dependent adult or elder person; K.S.A. § 21-5801 et seq. — theft / financial crimes; assault / battery; sexual offenses).

3. VULNERABLE ADULT INFORMATION

3.1. Full Legal Name: [________________________________]

3.2. Other Names Used / Aliases: [________________________________]

3.3. Date of Birth / Age: [__/__/____] / [______]

3.4. Gender: [________________________________]

3.5. Race / Ethnicity (optional): [________________________________]

3.6. Current Address / Location: [________________________________]

3.7. Telephone: [________________________________]

3.8. Living Arrangement:

• ☐ Own home (lives alone)
• ☐ Own home (lives with caregiver / family)
• ☐ Family member's home — relationship: [________________________________]
• ☐ Friend's home
• ☐ Adult family home
• ☐ Adult care home / nursing facility — name: [________________________________]
• ☐ Assisted living / Home Plus — name: [________________________________]
• ☐ Hospital — name: [________________________________]
• ☐ State institution / psychiatric hospital — name: [________________________________]
• ☐ Other: [________________________________]

3.9. Disabilities / Conditions Limiting Self-Protection (check all that apply):

• ☐ Dementia / Alzheimer's disease
• ☐ Other cognitive impairment
• ☐ Mental illness
• ☐ Intellectual / developmental disability
• ☐ Physical disability
• ☐ Sensory impairment (vision / hearing)
• ☐ Mobility limitation
• ☐ Chronic medical condition: [________________________________]
• ☐ Substance use / dependency
• ☐ Other: [________________________________]

3.10. Primary Language / Communication Needs: [________________________________]

3.11. Legal Capacity Status:

• ☐ No known capacity issue
• ☐ Power of Attorney executed — agent: [________________________________]
• ☐ Guardian — name and court: [________________________________]
• ☐ Conservator — name and court: [________________________________]
• ☐ Pending petition for guardianship/conservatorship

3.12. Emergency Contact (if known): [________________________________]

4. ALLEGED PERPETRATOR(S)

4.1. Caregiver Status (if perpetrator is caregiver):

• ☐ Family caregiver (unpaid)
• ☐ Hired private caregiver
• ☐ Agency-employed caregiver — agency: [________________________________]
• ☐ Adult care home staff — facility: [________________________________]
• ☐ Healthcare professional — license type: [________________________________]
• ☐ Power of Attorney / fiduciary
• ☐ Guardian / conservator

5. NATURE OF ABUSE, NEGLECT, OR EXPLOITATION

Check all that apply:

Physical Abuse (K.S.A. § 39-1430(a)(1)):

• ☐ Hitting, slapping, kicking, pushing
• ☐ Use of unlawful restraints
• ☐ Burns, cuts, bruising
• ☐ Sexual assault / sexual contact without consent
• ☐ Inappropriate use of medication / chemical restraint

Neglect (K.S.A. § 39-1430(c)) / Self-Neglect:

• ☐ Failure to provide adequate food / fluids
• ☐ Failure to provide adequate shelter / hygiene
• ☐ Failure to provide / administer medication
• ☐ Failure to obtain medical care
• ☐ Unsafe living conditions
• ☐ Inadequate supervision
• ☐ Self-neglect (adult unable to provide for own basic needs)
• ☐ Abandonment by caregiver

Mental / Emotional Abuse:

• ☐ Verbal threats, intimidation
• ☐ Humiliation, isolation
• ☐ Coercion / duress
• ☐ Stalking / harassment

Financial Exploitation (K.S.A. § 39-1430(b)):

• ☐ Misuse of POA / fiduciary authority
• ☐ Unauthorized withdrawals or transfers
• ☐ Theft of cash, property, valuables
• ☐ Forged checks / signatures
• ☐ Coerced or fraudulent change of will, deed, or beneficiary designation
• ☐ Coerced gifts or transfers
• ☐ Identity theft / credit card fraud
• ☐ Predatory lending / scam (lottery, romance, IRS imposter, tech support, grandparent scam, etc.)
• ☐ Failure to use adult's funds for adult's benefit
• ☐ Approximate dollar amount: $[__________]

6. FACTUAL NARRATIVE

State, in chronological order, the specific facts giving rise to the reasonable belief of abuse, neglect, or financial exploitation. Identify dates, times, locations, observed conditions, statements made by the adult or witnesses, and physical or documentary evidence. Distinguish between what the Reporter personally observed and what was reported by others.

[________________________________________________________________]

[________________________________________________________________]

[________________________________________________________________]

[________________________________________________________________]

[________________________________________________________________]

[________________________________________________________________]

[________________________________________________________________]

7. WITNESSES AND OTHER KNOWLEDGE

7.1. Documents / Evidence Available:

• ☐ Photographs of injuries / conditions
• ☐ Medical records
• ☐ Bank or financial records
• ☐ Powers of attorney / trust / will documents
• ☐ Email / text / voicemail communications
• ☐ Surveillance video
• ☐ Police report — agency / report number: [________________________________]
• ☐ Other: [________________________________]

8. IMMEDIATE RISK ASSESSMENT

8.1. Is the adult in immediate danger of serious harm or death? ☐ Yes ☐ No

If YES, the Reporter has called 911 / law enforcement at: [________________________________] on [__/__/____] at [____]:[____].

8.2. Is the adult medically stable? ☐ Yes ☐ No ☐ Unknown

8.3. Does the adult have current access to food, water, medication, and shelter? ☐ Yes ☐ No ☐ Unknown

8.4. Does the alleged perpetrator currently have access to the adult? ☐ Yes ☐ No ☐ Unknown

8.5. Are firearms or weapons present? ☐ Yes ☐ No ☐ Unknown

8.6. Recommended interim protective measures (Reporter's view):

• ☐ Welfare check by law enforcement
• ☐ Emergency medical evaluation
• ☐ Removal of perpetrator's access (no-contact / protection from abuse order)
• ☐ Temporary placement in safe setting
• ☐ Freeze of bank accounts pending investigation
• ☐ Emergency guardianship / conservatorship petition under K.S.A. § 59-3073
• ☐ Court-ordered protective services under K.S.A. § 39-1435

9. PRIOR REPORTS AND AGENCY CONTACTS

9.1. Prior reports of abuse, neglect, or exploitation involving this adult (to Reporter's knowledge):

9.2. Other agencies currently involved:

• ☐ DCF / APS
• ☐ KDADS Complaint Hotline
• ☐ KDHE
• ☐ Long-Term Care Ombudsman
• ☐ Law enforcement — agency: [________________________________]
• ☐ Hospital / medical provider: [________________________________]
• ☐ Court (probate / civil): [________________________________]
• ☐ Other: [________________________________]

10. MANDATORY REPORTER CERTIFICATION

I, [REPORTER NAME], certify the following under K.S.A. § 39-1431 (and/or K.S.A. § 39-1402, as applicable):

a. I have made or am making this report based on my reasonable belief that the above-named adult has been or is being subjected to abuse, neglect, or financial exploitation, or is in need of protective services;

b. I am making this report immediately upon receiving information giving rise to that reasonable belief, in compliance with the statutory duty to report;

c. The information set forth in this report is true and correct to the best of my knowledge and belief;

d. I am acting in good faith and not maliciously, and accordingly claim the immunity from civil and criminal liability provided by K.S.A. § 39-1431(f);

e. I understand that this report and its contents are confidential under K.S.A. § 39-1433 and may be disclosed only as authorized by statute;

f. I understand that knowing failure of a mandatory reporter to make a required report is a class B misdemeanor under K.S.A. § 39-1431(e);

g. I will cooperate with the investigating agency and provide additional information as requested.

Reporter signature: [________________________________]

Print name: [________________________________]

Date: [__/__/____]

11. SUBMISSION INSTRUCTIONS

11.1. Kansas Protection Report Center (24/7):

• Telephone: 1-800-922-5330
• TTY: 711 / Kansas Relay
• Web intake (KIPS): https://www.dcf.ks.gov/services/pps/pages/kips/kipswebintake.aspx

11.2. KDADS Adult Care Home Complaint Hotline (institutional track):

• Telephone: 1-800-842-0078
• Fax: 785-296-0256
• Email: [email protected]

11.3. Long-Term Care Ombudsman:

• Telephone: 1-877-662-8362
• Web: https://www.ombudsman.ks.gov/

11.4. Law Enforcement (if criminal conduct or immediate danger):

• Local law enforcement / 911
• Local county or district attorney's office

11.5. Method of submission used (check all that apply):

• ☐ Telephone — agency / time / staff name: [________________________________]
• ☐ Web intake — confirmation number: [________________________________]
• ☐ Fax — confirmation: [________________________________]
• ☐ Email — recipient: [________________________________]
• ☐ In-person — location: [________________________________]

11.6. The oral / telephonic report was made on: [__/__/____] at [____]:[____].

11.7. A written follow-up was submitted (where required by agency policy) on: [__/__/____].

12. KANSAS PRACTICE NOTES

• Two parallel statutes. K.S.A. § 39-1401 et seq. governs reports concerning residents of regulated facilities (adult care homes, hospitals, state institutions); K.S.A. § 39-1430 et seq. governs reports concerning vulnerable adults in the community. Both impose mandatory reporting duties on overlapping but not identical lists of professionals. When in doubt, the Kansas Protection Report Center (1-800-922-5330) routes appropriately.
• Definition of "adult." Under K.S.A. § 39-1430, an "adult" means a person 18 years of age or older alleged to be unable to protect such person's own interest and who is harmed or threatened with harm. Under K.S.A. § 39-1401, the term reaches residents of covered care settings without the same self-protection limitation.
• Timing. Mandatory reporters must report immediately upon obtaining information giving rise to reasonable belief. State agencies receiving reports must transmit them to DCF and to law enforcement promptly (within six hours during normal work days under current guidance — verify against current K.A.R.).
• Penalty for failure to report. Knowing failure to make a required report is a class B misdemeanor under K.S.A. § 39-1431(e) and § 39-1402(d). Professional licensing consequences may also follow.
• Immunity. Good-faith reporters are immune from civil and criminal liability and from professional discipline based solely on the report. Immunity does not extend to malicious or knowingly false reports.
• Confidentiality. Reports and investigative records are confidential under K.S.A. § 39-1433 and corresponding KDHE rules. Disclosure is permitted only as authorized by statute (e.g., to law enforcement, prosecutors, courts in protective proceedings, the adult or the adult's legal representative subject to redactions).
• Cross-reporting. When the suspected conduct may constitute a crime — including mistreatment of a dependent adult or elder person under K.S.A. § 21-5417, theft, sexual offenses, or assault — Reporter should cross-report to local law enforcement and the appropriate county or district attorney.
• Court-ordered protective services. When a vulnerable adult lacks capacity to consent and is in danger, K.S.A. § 39-1435 authorizes a court to order protective services. Emergency guardianship under K.S.A. § 59-3073 is the parallel mechanism in probate court.
• Tribal jurisdiction. Where the adult is an enrolled tribal member residing on tribal land, federal Indian Country jurisdiction may apply. Coordinate with tribal social services and BIA/IHS as appropriate.

13. SOURCES AND REFERENCES

• DCF — Report Adult Abuse, Neglect and Exploitation — https://www.dcf.ks.gov/services/PPS/Pages/ReportAdultAbuseNeglect.aspx
• DCF KIPS Web Intake — https://www.dcf.ks.gov/services/pps/pages/kips/kipswebintake.aspx
• DCF — Adult Protective Services Statutes (Appendix 10A) — https://www.dcf.ks.gov/services/PPS/Documents/PPM_Forms/Appendices/Appendix_10A.pdf
• KDADS Complaint Hotline — https://www.kdads.ks.gov/media-center/hotlines
• Kansas Office of the Long-Term Care Ombudsman — https://www.ombudsman.ks.gov/
• K.S.A. § 39-1430 (definitions) — https://ksrevisor.gov/statutes/chapters/ch39/039_014_0030.html
• K.S.A. § 39-1431 (reporting; immunity; penalty) — https://ksrevisor.gov/
• K.S.A. § 39-1401 et seq. (adult care home reporting) — https://ksrevisor.gov/
• K.S.A. § 21-5417 (mistreatment of a dependent adult or elder person)
• Kansas Adult Protective Services overview — https://rcilinc.org/wp-content/uploads/2012/10/Kansas-Adult-Protective-Services.pdf
• National Center on Elder Abuse — https://ncea.acl.gov/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Mandatory reporters must comply with statutory reporting timelines regardless of whether they consult counsel. Use of this template does not satisfy the statutory reporting duty unless a complete report is timely transmitted to the appropriate agency. A Kansas-licensed attorney should review the template and the Reporter's specific circumstances where there is doubt about the applicable statute, scope of immunity, or interaction with other professional duties.