Louisiana Adult / Elderly Protective Services Report

LOUISIANA ADULT / ELDERLY PROTECTIVE SERVICES REPORT

TABLE OF CONTENTS

1. Urgency Triage
2. Report Routing
3. Reporter Information
4. Alleged Victim Information
5. Alleged Perpetrator Information
6. Description of Abuse, Neglect, Exploitation, or Extortion
7. Risk Factors and Vulnerability
8. Witnesses and Other Sources
9. Prior Reports / Concurrent Investigations
10. Documentation Attached
11. Reporter Certification and Statutory Acknowledgment
12. Receiving-Agency Confirmation
13. Louisiana Practice Notes
14. Sources and References

1. URGENCY TRIAGE

Mark all that apply. If any item in the "EMERGENCY" group is checked, call 911 first.

EMERGENCY (call 911 before completing this report):

• ☐ Alleged victim is in immediate danger of serious bodily harm or death.
• ☐ Crime is in progress (assault, battery, sexual assault, kidnapping).
• ☐ Alleged victim has untreated life-threatening medical condition.
• ☐ Weapon involved or threatened.

URGENT (report within 24 hours):

• ☐ Recent injuries, untreated medical conditions, or rapid decline.
• ☐ Escalating financial exploitation (active transfers, ATM withdrawals, deed transfers).
• ☐ Caretaker absent or impaired, leaving victim without basic care.

ROUTINE (still report immediately):

• ☐ Pattern of neglect, isolation, or psychological abuse without immediate physical risk.
• ☐ Suspected exploitation that appears completed or stable.

2. REPORT ROUTING

Identify the correct receiving agency based on the victim profile and setting:

Date and time of telephonic report: [__/__/____] at [____] [AM / PM]

Receiving worker / intake-ID number (if assigned): [________________________________]

Method of report: ☐ Telephone ☐ Online portal ☐ In person ☐ Written follow-up

3. REPORTER INFORMATION

4. ALLEGED VICTIM INFORMATION

5. ALLEGED PERPETRATOR INFORMATION

(Provide for each individual; attach additional sheets as needed.)

6. DESCRIPTION OF ABUSE, NEGLECT, EXPLOITATION, OR EXTORTION

Mark all categories that apply (definitions per La. R.S. § 15:1503 and La. R.S. § 14:403.2):

• ☐ Physical abuse — hitting, slapping, pushing, restraining, force-feeding, improper use of restraints/medication.
• ☐ Sexual abuse — non-consensual sexual contact, exploitation of a person without capacity to consent.
• ☐ Emotional / psychological abuse — threats, intimidation, humiliation, isolation, infantilization.
• ☐ Caretaker neglect — failure to provide food, water, hygiene, shelter, medication, supervision, or medical care.
• ☐ Self-neglect — adult unable to meet own basic needs.
• ☐ Abandonment — desertion by caregiver.
• ☐ Financial exploitation — improper use of funds, property, or assets; theft; coercion; misuse of POA/curatorship; deed transfer; account transfers; new credit accounts.
• ☐ Extortion — obtaining property by wrongful use of force, threat, or fear.
• ☐ Health care fraud / undue influence in connection with medical care.

Narrative. State the facts in chronological order. Use the victim's own words where possible (in quotation marks). Avoid conclusions; describe what was seen, heard, or measured. Continue on additional sheets as needed.

[__________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________]

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

Location(s) of incident(s): [________________________________]

Frequency / pattern: ☐ One-time ☐ Sporadic ☐ Recurring ☐ Escalating ☐ Continuous

Specific injuries or harm observed: [________________________________]

Estimated dollar loss (financial exploitation): $ [____]

7. RISK FACTORS AND VULNERABILITY

• ☐ Victim is age 60 or older.
• ☐ Victim has a physical or developmental disability.
• ☐ Victim has cognitive impairment / dementia / Alzheimer's disease.
• ☐ Victim is dependent on alleged perpetrator for care, housing, or finances.
• ☐ Victim is socially isolated; perpetrator restricts visitors or phone access.
• ☐ Victim has limited or no English proficiency.
• ☐ Victim has communication impairment (hearing, vision, speech).
• ☐ Victim has been moved recently or unexplained changes in residence.
• ☐ Victim's medications or finances have been altered without explanation.
• ☐ Victim has expressed fear of perpetrator.
• ☐ History of domestic violence in the household.
• ☐ Recent loss of spouse / primary caregiver.

8. WITNESSES AND OTHER SOURCES

9. PRIOR REPORTS / CONCURRENT INVESTIGATIONS

• ☐ Prior APS / EPS report. Date(s): [__/__/____]; Agency: [____]; Outcome: [____]
• ☐ Law-enforcement report. Agency: [____]; Report #: [____]
• ☐ LDH Health Standards Section complaint. Date: [__/__/____]; Complaint #: [____]
• ☐ Long-Term Care Ombudsman. Date: [__/__/____]; Case #: [____]
• ☐ Civil restraining order / protective order. Court: [____]; Docket #: [____]
• ☐ Pending interdiction / curatorship proceeding. Court: [____]; Docket #: [____]
• ☐ Adult Day Health / home-health agency on record. Agency: [____]
• ☐ Bank or financial institution suspicious-activity report (SAR / Reg E).

10. DOCUMENTATION ATTACHED

• ☐ Photographs of injuries, environment, or documents (date-stamped).
• ☐ Medical records / hospital discharge summaries.
• ☐ Bank statements, canceled checks, ATM logs.
• ☐ Property records, deeds, mortgage documents.
• ☐ Power-of-attorney instrument or curatorship judgment.
• ☐ Text messages, emails, voicemails.
• ☐ Witness statements (signed and dated).
• ☐ Caregiver schedule, employment records.
• ☐ Service-provider notes (home health, hospice, ADHC).
• ☐ Other: [________________________________]

11. REPORTER CERTIFICATION AND STATUTORY ACKNOWLEDGMENT

I, [REPORTER NAME], declare:

1. I am making this report in good faith based on facts and observations available to me as of the date below.
2. I understand that under La. R.S. § 14:403.2 and La. R.S. § 15:1504, every person in Louisiana is a mandatory reporter of suspected abuse, neglect, exploitation, or extortion of an adult who cannot physically or mentally protect himself or herself.
3. I understand that knowingly and willfully failing to report is a misdemeanor punishable by a fine of not more than five hundred dollars ($500), imprisonment for not more than six months, or both. La. R.S. § 14:403.2(C); La. R.S. § 15:1504(C).
4. I understand that a person who reports in good faith and cooperates in any ensuing investigation is immune from civil or criminal liability for that report. La. R.S. § 14:403.2(D); La. R.S. § 15:1505.
5. I understand that my identity as reporter is confidential under La. R.S. § 15:1511, subject only to disclosure to law enforcement or by court order.
6. I have not investigated, confronted the alleged perpetrator, or taken any action that could compromise an EPS/APS or law-enforcement investigation.

[________________________________]

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

(If signed by an attorney on behalf of a client-reporter, attach Form 2848-equivalent authorization or written engagement.)

12. RECEIVING-AGENCY CONFIRMATION

(To be completed at intake by the receiving agency or by the reporter for records.)

13. LOUISIANA PRACTICE NOTES

• Universal mandatory reporting. Louisiana is among the strictest jurisdictions: every person — not only specified professionals — is a mandatory reporter when they have reasonable cause to believe an adult unable to protect himself or herself is being abused, neglected, exploited, or extorted. La. R.S. § 14:403.2(B).
• Two parallel APS systems. GOEA's Elderly Protective Services has statutory authority over adults 60+ (La. R.S. § 46:932 et seq.; La. R.S. § 15:1503's "adult protection agency" definition). LDH operates Adult Protective Services for adults 18-59 with disabilities (La. R.S. § 15:1501 et seq.). Confirm the victim's age and refer accordingly; intake lines will cross-route if needed.
• Facility residents. Reports involving residents of nursing facilities, ICF/DD, assisted-living facilities, or adult residential-care providers should also be made to the LDH Health Standards Section (1-888-810-1819) and to the State Long-Term Care Ombudsman (1-866-632-0922). Facility staff have additional reporting duties under federal law (42 U.S.C. § 1396r and 42 C.F.R. § 483.12 — "Elder Justice Act" reporting for crimes against residents of long-term care facilities receiving federal funds, with reporting timelines as short as two hours for serious bodily injury).
• Immunity. La. R.S. § 14:403.2(D) and La. R.S. § 15:1505 grant absolute civil and criminal immunity to good-faith reporters and cooperating investigators. Bad-faith or malicious reporting is not immunized.
• Confidentiality. La. R.S. § 15:1511 makes reporter identity and case records confidential, with disclosure only to law enforcement, courts (under court order), and authorized agency staff.
• Capacity issues. If the alleged victim refuses services and capacity is in doubt, EPS/APS may petition for emergency protective custody or refer to the district attorney for an interdiction proceeding under La. C.C. arts. 389-399. Counsel should evaluate Power of Attorney revocation and curatorship as alternatives.
• Financial exploitation by fiduciaries. Louisiana banks have authority to delay or refuse transactions when financial exploitation is suspected (cf. La. R.S. § 6:1101 et seq. and the NASAA Senior Safe model). Coordinate with the institution's BSA/AML or fraud-investigations unit and file a Suspicious Activity Report where warranted.
• Criminal cross-referrals. Conduct constituting financial exploitation may also constitute theft of an aged person or person with infirmity (La. R.S. § 14:67.21), exploitation of the infirmed (La. R.S. § 14:93.4), or cruelty to the infirmed (La. R.S. § 14:93.3). EPS/APS routinely cross-reports to local sheriffs and the State Police Bureau of Investigation.
• No investigation by reporter. The reporter's duty ends with making the report. Do not interview the perpetrator, gather records by deception, or take custody of the victim absent consent and capacity.

14. SOURCES AND REFERENCES

• La. R.S. § 14:403.2 (mandatory reporting; immunity; penalty) — https://legis.la.gov/
• La. R.S. § 15:1501 et seq. (Adult Protective Services Act) — https://legis.la.gov/
• La. R.S. § 15:1503 (definitions); § 15:1504 (mandatory reporting); § 15:1505 (immunity); § 15:1511 (confidentiality)
• La. R.S. § 14:67.21 (theft of the aged or infirm)
• La. R.S. § 14:93.3 (cruelty to the infirmed); § 14:93.4 (exploitation of the infirmed)
• La. R.S. § 46:932 et seq. (Governor's Office of Elderly Affairs)
• 42 U.S.C. § 1397j et seq. (Elder Justice Act)
• 42 U.S.C. § 1396r and 42 C.F.R. § 483.12 (LTC facility reporting)
• LDH Adult Protective Services — https://ldh.la.gov/page/adult-protective-services
• GOEA Elderly Protective Services — https://goea.louisiana.gov/
• Elderly Protective Services hotline — 1-833-577-6532 / 225-342-0144
• LDH APS hotline (adults 18-59 with disabilities) — 1-800-898-4910
• LDH HSS Nursing Home Abuse Hotline — 1-888-810-1819
• Louisiana Long-Term Care Ombudsman — 1-866-632-0922

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. If a person is in immediate danger, call 911 first. Mandatory reporters must report directly to the appropriate agency without delay; this template is an organizational aid, not a substitute for the report itself.