Kentucky Adult Protective Services (APS) Report — Vulnerable Adult

KENTUCKY ADULT PROTECTIVE SERVICES REPORT — VULNERABLE ADULT

EMERGENCY? Call 911 first.

Kentucky APS / Child & Adult Abuse Reporting Hotline: 1-877-597-2331 (toll-free, 1-877-KYSAFE1)
Online reporting: https://prd.webapps.chfs.ky.gov/reportabuse/
After-hours / weekend emergencies: call local law enforcement or 911. The state hotline is staffed during business hours; emergencies are handled 24/7 through 911 and on-call DCBS investigators.

TABLE OF CONTENTS

1. Reporter Information
2. Statutory Basis for Report
3. Vulnerable Adult / Subject Information
4. Alleged Perpetrator(s)
5. Description of Abuse, Neglect, or Exploitation
6. Evidence and Witnesses
7. Risk Assessment and Immediate Safety
8. Verbal-Report Confirmation
9. Statement of Good Faith and Immunity
10. Distribution List
11. Reporter Certification and Signature
12. Kentucky Statutory Reference Card
13. Sources and References

1. REPORTER INFORMATION

2. STATUTORY BASIS FOR REPORT

This report is submitted pursuant to:

• ☐ KRS § 209.030(2) — Mandatory reporting of suspected abuse, neglect, or exploitation of an adult.
• ☐ 922 KAR 5:070 — Cabinet regulation governing reporting and investigation procedures.
• ☐ KRS § 209.020 — Statutory definitions of "adult," "abuse," "neglect," "exploitation," and "spouse."
• ☐ Other professional or facility reporting obligation: [________________________________]

Statutory standard: "Any person ... having reasonable cause to suspect that an adult has suffered abuse, neglect, or exploitation, shall report or cause reports to be made in accordance with the provisions of this chapter." KRS § 209.030(2).

Definition of "adult": A person 18 years of age or older who, because of mental or physical dysfunctioning, is unable to manage his or her own resources, carry out the activity of daily living, or protect himself or herself from neglect, exploitation, or a hazardous or abusive situation without assistance from others, and who may be in need of protective services. KRS § 209.020(4).

Date and time of reasonable cause forming: [__/__/____] at [__:__] ☐ a.m. ☐ p.m.

3. VULNERABLE ADULT / SUBJECT INFORMATION

4. ALLEGED PERPETRATOR(S)

For each suspected perpetrator, complete the following block:

5. DESCRIPTION OF ABUSE, NEGLECT, OR EXPLOITATION

Check each statutory category that applies and provide a particularized factual description.

A. Abuse — KRS § 209.020(8)

"The infliction of injury, sexual abuse, unreasonable confinement, intimidation, or punishment that results in physical pain or injury, including mental injury."

• ☐ Physical assault (describe): [________________________________]
• ☐ Sexual abuse / assault: [________________________________]
• ☐ Unreasonable confinement / restraint: [________________________________]
• ☐ Intimidation, threats, verbal abuse: [________________________________]
• ☐ Mental / psychological injury: [________________________________]
• ☐ Improper use of chemical or physical restraints (facility setting): [________________________________]

B. Neglect — KRS § 209.020(16)

"A situation in which an adult is unable to perform or obtain for himself or herself the goods or services that are necessary to maintain his or her health or welfare, or the deprivation of services by a caretaker that are necessary to maintain the health and welfare of an adult."

• ☐ Caretaker withholding food, water, hygiene, or medical care: [__________]
• ☐ Pressure ulcers / wounds suggestive of immobility neglect: [__________]
• ☐ Medication mismanagement (over- or under-medication): [__________]
• ☐ Unsanitary or hazardous living conditions: [__________]
• ☐ Self-neglect (adult unable to perform ADLs without assistance): [__________]
• ☐ Abandonment: [__________]

C. Exploitation — KRS § 209.020(9)

"Obtaining or using another person's resources, including but not limited to funds, assets, or property, by deception, intimidation, or similar means, with the intent to deprive the person of those resources."

• ☐ Theft of cash, checks, or property: [__________]
• ☐ Misuse of bank accounts, debit/credit cards, or PIN: [__________]
• ☐ Forgery / unauthorized signature: [__________]
• ☐ Misuse of Power of Attorney or fiduciary position: [__________]
• ☐ Coerced changes to deed, will, beneficiary designation: [__________]
• ☐ Improperly obtained loans, gifts, or transfers: [__________]
• ☐ Online / telephone fraud targeting the adult: [__________]
• ☐ Identity theft / Social Security or Medicare number misuse: [__________]

D. Narrative

Provide a chronological, fact-based narrative of what was observed, when, where, and what was said. Use exact quotations where possible. Avoid speculation and conclusory labels.

[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]

6. EVIDENCE AND WITNESSES

A. Physical and Documentary Evidence

• ☐ Photographs of injuries / environment (date-stamped) — secured at: [LOCATION]
• ☐ Medical records / hospital chart — provider: [________________________________]
• ☐ Bank records / canceled checks / statements
• ☐ Recorded threats, voicemails, text messages — preserved on: [DEVICE]
• ☐ Soiled / blood-stained clothing or bedding (preserved per chain of custody)
• ☐ Police report number (if filed): [________________________________]
• ☐ Other: [________________________________]

B. Witnesses

7. RISK ASSESSMENT AND IMMEDIATE SAFETY

Protective Action Recommended (advisory)

• ☐ Emergency Protective Services petition under KRS § 209.140 / § 209.150 (court-ordered emergency intervention).
• ☐ Domestic Violence Order under KRS Chapter 403 (if domestic relationship exists).
• ☐ Inter-Personal Protective Order under KRS Chapter 456 (non-domestic).
• ☐ Emergency guardianship petition under KRS § 387.740 (Disability Court).
• ☐ Bank freeze under KRS § 209.165 (financial institution authority to suspend transactions on suspected exploitation).
• ☐ Law-enforcement referral for criminal investigation under KRS Ch. 508 / Ch. 514.

8. VERBAL-REPORT CONFIRMATION

This written report is submitted in addition to (not in lieu of) the verbal/telephonic report required under KRS § 209.030(2). Reports must be made "immediately" upon formation of reasonable cause.

9. STATEMENT OF GOOD FAITH AND IMMUNITY

This report is made in good faith based on the reporter's reasonable cause to suspect abuse, neglect, or exploitation of an adult as defined in KRS Chapter 209. Pursuant to KRS § 209.050, "anyone acting upon reasonable cause in the making of any report or investigation or participating in the filing of a petition to obtain injunctive relief or emergency protective services for an adult pursuant to this chapter ... shall have immunity from any civil or criminal liability that might otherwise be incurred or imposed."

The reporter has not made and does not make any statement of fact known by the reporter to be false. The reporter understands that knowing or willful filing of a false report may itself constitute a criminal offense.

10. DISTRIBUTION LIST

This written record has been distributed to:

• ☐ Kentucky Department for Community Based Services — Adult Protection Branch (via fax / portal / mail)
• ☐ [COUNTY] County DCBS Family Support Office
• ☐ Local law enforcement: [AGENCY / CASE #]
• ☐ Facility administrator (if institutional setting): [NAME]
• ☐ Long-Term Care Ombudsman (if facility): [OMBUDSMAN OFFICE]
• ☐ Reporter's employer / compliance officer: [NAME]
• ☐ Retained internally (reporter file) — DO NOT DISCLOSE without legal authority; report is confidential under KRS § 209.140.

11. REPORTER CERTIFICATION AND SIGNATURE

I certify that the foregoing report is true and correct to the best of my knowledge and belief, that it is submitted in good faith pursuant to KRS § 209.030, and that I claim the immunity afforded by KRS § 209.050.

Reporter signature: [________________________________]

Printed name: [________________________________]

Title: [________________________________]

Date: [__/__/____]

Time: [__:__] ☐ a.m. ☐ p.m.

(If submitted by counsel on behalf of a reporter:)

Counsel signature: [________________________________]
KY Bar No.: [__________]
Firm: [________________________________]
Date: [__/__/____]

12. KENTUCKY STATUTORY REFERENCE CARD

13. SOURCES AND REFERENCES

• KRS Chapter 209 (Protection of Adults) — https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=38151
• KRS § 209.030 (Mandatory reporting) — https://apps.legislature.ky.gov/law/statutes/statute.aspx?id=8182
• KRS § 209.050 (Immunity) — https://apps.legislature.ky.gov/law/statutes/
• KRS § 209.990 (Penalties) — https://apps.legislature.ky.gov/law/statutes/
• KRS § 508.090 – § 508.120 (Criminal abuse) — https://apps.legislature.ky.gov/law/statutes/chapter.aspx?id=37934
• 922 KAR 5:070 (APS reporting & investigation) — https://apps.legislature.ky.gov/law/kar/titles/922/
• Kentucky Cabinet for Health and Family Services — Adult Protection Branch — https://www.chfs.ky.gov/agencies/dcbs/dpp/apb/Pages/default.aspx
• Online reporting portal — https://prd.webapps.chfs.ky.gov/reportabuse/home.aspx
• Statewide Hotline: 1-877-597-2331 (1-877-KYSAFE1)
• Kentucky Long-Term Care Ombudsman — https://www.chfs.ky.gov/agencies/dail/Pages/ltcomb.aspx
• Bluegrass Elder Abuse Prevention Council — https://bluegrasseapc.com/
• 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 should make a verbal report to the Kentucky APS hotline (1-877-597-2331) or 911 immediately upon forming reasonable cause; this written record is supplemental. A Kentucky-licensed attorney should be consulted for any question regarding scope of immunity, confidentiality, professional licensure consequences, or follow-up litigation.