Adult Protective Services Report — Maine

ADULT PROTECTIVE SERVICES REPORT — STATE OF MAINE

Statutory Reporting Hotline (24/7): 1-800-624-8404
Maine Relay (TTY): 711
Emergency / imminent harm: 9-1-1

REQUIRED IMMEDIATE TELEPHONE REPORT. Mandated reporters must report by telephone immediately upon forming reasonable cause to suspect abuse, neglect, or exploitation of an incapacitated or dependent adult. 22 M.R.S. § 3477. This written form supplements but does not replace the telephonic report.

TABLE OF CONTENTS

1. Reporter Information
2. Reporter Status and Statutory Basis
3. Subject Adult Information
4. Alleged Perpetrator Information
5. Nature and Description of Abuse, Neglect, or Exploitation
6. Imminent-Danger Assessment
7. Witnesses and Evidence
8. Prior Reports / History
9. Confidentiality, Immunity, and Penalties Acknowledgment
10. Telephonic Report Log
11. Reporter Certification
12. Sources and References

1. REPORTER INFORMATION

2. REPORTER STATUS AND STATUTORY BASIS

I am submitting this report as (select all that apply):

☐ Mandated reporter under 22 M.R.S. § 3477(1). Specific category:

• ☐ Physician / osteopathic physician / physician assistant
• ☐ Dentist / dental hygienist
• ☐ Registered nurse / licensed practical nurse / advanced practice RN
• ☐ Social worker (LCSW, LMSW, LSW)
• ☐ Psychologist / mental-health counselor
• ☐ Pharmacist
• ☐ Physical, occupational, speech, or respiratory therapist
• ☐ Emergency medical services personnel (EMT, paramedic)
• ☐ Law enforcement officer / corrections officer
• ☐ Medical examiner
• ☐ Clergy (subject to penitential-communication exception)
• ☐ Sexual-assault counselor / domestic-violence advocate
• ☐ Chair of a professional-licensing board
• ☐ Person who has assumed full, intermittent, or occasional responsibility for the care or custody of an incapacitated or dependent adult, with or without compensation
• ☐ Person in an administrative or trust position within a religious institution
• ☐ Volunteer or employee transportation provider for incapacitated or dependent adults
• ☐ Other category enumerated in § 3477(1): [____________]

☐ Permissive (non-mandated) reporter under 22 M.R.S. § 3477(3). Submitting voluntarily.

Reasonable cause to suspect. I have reasonable cause to suspect that an incapacitated or dependent adult, as those terms are defined at 22 M.R.S. § 3472, has been or is likely to be:

☐ Abused (physical, emotional, or sexual)
☐ Neglected (including self-neglect)
☐ Financially exploited

The basis of my reasonable cause is set forth in §§ 5 and 7 below.

3. SUBJECT ADULT INFORMATION

Capacity / dependency indicators (basis for "incapacitated or dependent adult" status under § 3472):

☐ Cognitive impairment / dementia / Alzheimer's
☐ Severe mental illness
☐ Intellectual or developmental disability
☐ Physical disability requiring assistance with ADLs
☐ Stroke / TBI / neurological condition
☐ Substance use disorder impairing capacity
☐ Advanced age with frailty
☐ Adjudicated incapacitated / under guardianship
☐ Other: [________________________________]

Describe the adult's apparent ability to protect themselves, communicate, and meet daily needs:

[________________________________]

4. ALLEGED PERPETRATOR INFORMATION

(Provide for each alleged perpetrator known. If unknown, write "unknown.")

5. NATURE AND DESCRIPTION OF ABUSE, NEGLECT, OR EXPLOITATION

5.1 Type(s) of harm suspected (select all that apply)

Abuse:
☐ Physical (hitting, slapping, pushing, restraint marks, unexplained injuries)
☐ Sexual (any non-consensual contact; or contact with adult lacking capacity to consent)
☐ Emotional / psychological (threats, intimidation, isolation, humiliation)
☐ Verbal (yelling, demeaning language)

Neglect:
☐ Caregiver neglect (failure to provide food, hygiene, shelter, medical care, supervision)
☐ Self-neglect (adult unable to meet own needs and at risk of serious harm)
☐ Medical neglect (denied medication, denied medical appointments, untreated conditions)
☐ Abandonment

Financial Exploitation:
☐ Theft of money, checks, or valuables
☐ Misuse of power of attorney / agent authority
☐ Unauthorized account withdrawals or transfers
☐ Forged signatures
☐ Coerced changes to deeds, wills, beneficiary designations
☐ Scams (romance, IRS, grandchild, lottery, tech-support, contractor)
☐ Misuse of Social Security representative payee authority
☐ Undue influence / new "friend" controlling assets
☐ Withholding necessities to coerce financial transactions

5.2 Narrative description

Describe what was observed, when, where, how, by whom, and how it became known to the reporter. Use clear, objective, observation-based language. Quote statements made by the adult or perpetrator verbatim where possible. Distinguish between firsthand observation and statements made by others.

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

5.3 Physical findings (if observed)

5.4 Financial indicators (if applicable)

5.5 Date(s) and place(s) of incident(s)

6. IMMINENT-DANGER ASSESSMENT

☐ The adult is in imminent danger of serious bodily injury or death. 9-1-1 has been called. Time of 9-1-1 call: [__:__] on [__/__/____]; CAD/incident # [____________].
☐ The adult is in imminent danger of significant financial loss; financial institution has been notified.
☐ The adult is currently isolated by the suspected perpetrator, limiting law-enforcement or APS access.
☐ The adult lacks capacity to refuse services and is at risk of harm without intervention.
☐ No imminent danger identified at this time, but ongoing risk warrants APS investigation.

Specific indicators of imminent danger:

[________________________________]

7. WITNESSES AND EVIDENCE

7.1 Witnesses

7.2 Evidence in reporter's possession or available

☐ Photographs (specify): [____________]
☐ Medical records / chart notes
☐ Bank statements / cancelled checks
☐ Power of attorney or trust documents
☐ Text messages, emails, voicemails
☐ Video / audio recordings
☐ Police reports / incident reports
☐ Facility incident reports
☐ Other: [________________________________]

Reporter's intended preservation steps: [________________________________]

8. PRIOR REPORTS / HISTORY

9. CONFIDENTIALITY, IMMUNITY, AND PENALTIES ACKNOWLEDGMENT

I acknowledge that:

1. Confidentiality. Reports made to APS, including the identity of the reporter, are confidential records under 22 M.R.S. § 3479 and may be disclosed only as authorized by statute or court order.
2. Immunity. A person participating in good faith in reporting under the Adult Protective Services Act, or in any related investigation or judicial proceeding, is immune from any civil or criminal liability that might otherwise result. There is a rebuttable presumption of good faith. 22 M.R.S. § 3479-A.
3. Failure to report. A mandated reporter who knowingly fails to report suspected abuse, neglect, or exploitation commits a Class E crime under 22 M.R.S. § 3478, and may also be subject to professional-licensing discipline.
4. False reports. Knowingly making a false report exposes the reporter to civil and criminal liability and forfeits the immunity of § 3479-A.
5. No retaliation. Maine law prohibits retaliation against a mandated reporter; supervisors may not obstruct the reporting process.

10. TELEPHONIC REPORT LOG

11. REPORTER CERTIFICATION

I certify under penalty of perjury under the laws of the State of Maine that the foregoing report is true and correct to the best of my knowledge and belief, and that I am submitting it in good faith pursuant to 22 M.R.S. ch. 958-A. I understand that the report and my identity are confidential under 22 M.R.S. § 3479, and that I am protected from civil and criminal liability for a good-faith report under 22 M.R.S. § 3479-A.

12. SOURCES AND REFERENCES

• 22 M.R.S. ch. 958-A, Adult Protective Services Act: https://www.mainelegislature.org/legis/statutes/22/title22ch958-Asec0.html
• 22 M.R.S. § 3477 (Persons mandated to report): https://www.mainelegislature.org/legis/statutes/22/title22sec3477.html
• 22 M.R.S. § 3478 (Failure to report; penalty): https://www.mainelegislature.org/legis/statutes/22/title22sec3478.html
• 22 M.R.S. § 3479 (Confidentiality of records): https://www.mainelegislature.org/legis/statutes/22/title22sec3479.html
• 22 M.R.S. § 3479-A (Immunity from liability): https://legislature.maine.gov/statutes/22/title22sec3479-A.html
• Maine DHHS, Office of Aging and Disability Services (OADS) — Adult Protective Services: https://www.maine.gov/dhhs/oads/get-support/aps
• Report Abuse, Neglect or Exploitation: https://www.maine.gov/dhhs/oads/get-support/aps/report-abuse-neglect-exploitation
• APS Mandated Reporters: https://www.maine.gov/dhhs/oads/get-support/aps/mandated-reporters
• 10-149 C.M.R. ch. 1 (OADS APS System rule): https://www.maine.gov/sos/cec/rules/10/chaps10.htm
• Maine Council for Elder Abuse Prevention: https://elderabuseprevention.info
• Maine Long-Term Care Ombudsman Program: https://www.maineombudsman.org

END OF ADULT PROTECTIVE SERVICES REPORT