Nebraska Adult Protective Services Report (Vulnerable Adult Abuse, Neglect, or Exploitation)

NEBRASKA ADULT PROTECTIVE SERVICES REPORT

TABLE OF CONTENTS

1. Reporter Information
2. Vulnerable Adult Information
3. Alleged Perpetrator Information
4. Type of Maltreatment Reported
5. Narrative of Events
6. Evidence and Witnesses
7. Immediate Risk Assessment
8. Prior Reports and Concurrent Notifications
9. Statutory Basis and Mandatory-Reporter Certification
10. Reporter Signature
11. Nebraska Practice Notes
12. Sources and References

1. REPORTER INFORMATION

2. VULNERABLE ADULT INFORMATION

2.1. Statutory definition. Under Neb. Rev. Stat. § 28-371, a "vulnerable adult" is any person 18 years of age or older who has a substantial mental or functional impairment or for whom a guardian or conservator has been appointed. The reporter has reasonable cause to believe the adult identified above meets this definition for the reasons stated in Section 5.

3. ALLEGED PERPETRATOR INFORMATION

4. TYPE OF MALTREATMENT REPORTED

(Check all that apply; definitions per Neb. Rev. Stat. § 28-351 through § 28-371.)

• ☐ Physical abuse — knowing or intentional infliction of physical injury, unreasonable confinement, cruel punishment, sexual abuse, or sexual assault.
• ☐ Sexual abuse / sexual assault — any non-consensual sexual contact or contact with a person legally incapable of consent.
• ☐ Emotional or psychological abuse — verbal threats, intimidation, humiliation, or harassment causing mental anguish.
• ☐ Neglect — failure to provide minimum amount of food, clothing, shelter, supervision, hygiene, or medical care reasonably necessary to maintain physical and mental health.
• ☐ Self-neglect — vulnerable adult is unable to provide for his or her own basic needs and refuses or is unable to accept assistance.
• ☐ Exploitation / financial exploitation — wrongful or unauthorized taking, withholding, appropriation, or use of the vulnerable adult's money, real property, or personal property by any person, including by undue influence, coercion, deception, intimidation, or breach of fiduciary duty.
• ☐ Abandonment — desertion of a vulnerable adult by a caregiver who has assumed responsibility for the adult's care.
• ☐ Other: [__________________________]

5. NARRATIVE OF EVENTS

5.1. Date(s) and location(s) of incident(s): [__/__/____] at [________________________________].

5.2. Detailed factual narrative. State chronologically what was observed, told to the reporter, or otherwise learned, identifying the source of each fact (direct observation, statement of the vulnerable adult, statement of a witness, document, etc.). Avoid conclusions; record specifics.

[________________________________________________________________________________________________________________________________________________________________________]

[________________________________________________________________________________________________________________________________________________________________________]

[________________________________________________________________________________________________________________________________________________________________________]

5.3. Observable injuries or conditions: [describe bruises, weight loss, pressure ulcers, dehydration, soiled clothing, fearful demeanor, withdrawn affect, missing funds, unexplained transfers, new "friends" with control of finances, etc.].

5.4. Statements by the vulnerable adult (verbatim where possible): [____________________________________________].

5.5. Pattern, frequency, and recency: [____________________________________________].

6. EVIDENCE AND WITNESSES

6.1. Physical / documentary evidence available:

• ☐ Photographs (date-stamped)
• ☐ Medical records / chart notes
• ☐ Bank or brokerage statements
• ☐ Written communications (text, email, letter)
• ☐ Surveillance video
• ☐ Receipts / invoices / contracts
• ☐ Power of Attorney or trust documents
• ☐ Prior incident reports / facility logs
• ☐ Police report number: [________]
• ☐ Other: [____________]

6.2. Witnesses:

7. IMMEDIATE RISK ASSESSMENT

7.1. Is the vulnerable adult in immediate danger of serious physical harm? ☐ Yes ☐ No

7.2. Has 911 been notified? ☐ Yes — Agency: [________] Report #: [________] ☐ No

7.3. Is the alleged perpetrator presently with or able to access the vulnerable adult? ☐ Yes ☐ No ☐ Unknown

7.4. Does the vulnerable adult have decision-making capacity to consent to or refuse APS intervention? ☐ Yes ☐ No ☐ Unclear — see Section 2

7.5. Recommended emergency steps (from reporter's vantage): [____________________________________________].

8. PRIOR REPORTS AND CONCURRENT NOTIFICATIONS

8.1. Prior APS reports regarding this adult known to reporter: [__________] (date(s) / outcome if known).

8.2. Concurrent notifications made by reporter:

• ☐ Local law enforcement — Agency: [________] Report #: [________]
• ☐ Nebraska State Long-Term Care Ombudsman (1-800-942-7830)
• ☐ DHHS Public Health Division — Office of Long-Term Care Facilities (licensure complaint)
• ☐ Facility administrator / director of nursing
• ☐ Family or designated emergency contact (where appropriate and not contraindicated)
• ☐ Nebraska Attorney General — Medicaid Fraud and Patient Abuse Unit (where institutional)
• ☐ Bank's elder financial abuse / fraud unit (financial exploitation)
• ☐ Other: [____________]

9. STATUTORY BASIS AND MANDATORY-REPORTER CERTIFICATION

9.1. Statutory authority. This report is made pursuant to the Nebraska Adult Protective Services Act, Neb. Rev. Stat. §§ 28-348 to 28-387. Reporter has reasonable cause to believe the adult identified in Section 2 has been subjected to abuse, neglect, or exploitation, or observed the adult being so subjected, and is therefore obligated to report under § 28-372.

9.2. Hotline reporting. A telephonic report was made to the Nebraska APS Hotline at 1-800-652-1999 on [__/__/____] at [__:__]. This written narrative is submitted to confirm and supplement the telephonic report.

9.3. Immunity. Reporter is acting in good faith and is therefore immune from civil and criminal liability under Neb. Rev. Stat. § 28-375, except for malfeasance in office, willful or wanton neglect of duty, or false statements made with malicious intent.

9.4. Confidentiality. Reporter requests that identifying information remain confidential to the maximum extent permitted by Neb. Rev. Stat. § 28-376 and § 28-377.

9.5. Failure to report. Reporter understands that knowingly failing to make a required report under § 28-372 is a Class III misdemeanor under Neb. Rev. Stat. § 28-386.

10. REPORTER SIGNATURE

I certify under penalty of perjury under the laws of the State of Nebraska that the foregoing report is true and correct to the best of my knowledge and belief, and that I am making this report in good faith pursuant to the Nebraska Adult Protective Services Act.

[________________________________]

[REPORTER NAME]

Title: [____________]

Date: [__/__/____]

(Optional) Acknowledged before me this [____] day of [_______________], 20[____].

[________________________________]

Notary Public — State of Nebraska

(My Commission Expires: [__/__/____])

11. NEBRASKA PRACTICE NOTES

• Hotline. Nebraska APS reports go to 1-800-652-1999 (24/7). The hotline serves both child and adult protective services intake. Online reporting is also available through DHHS at https://dhhs.ne.gov/Pages/Adult-Protective-Services.aspx.
• Who must report. Nebraska's mandatory-reporter standard is broad: "any person" with reasonable cause to believe a vulnerable adult has been abused, neglected, or exploited, or who observes the adult being so subjected. This goes beyond the narrower professional-only standards in some states.
• Time frame. Reports must be made as soon as reasonably possible. There is no statutory grace period; documentation of the time the reporter formed reasonable cause should be maintained.
• Investigation timelines. Under § 28-373, DHHS must initiate an investigation within applicable response timelines (priority cases within 24 hours; standard cases within statutory windows). DHHS may coordinate with law enforcement under § 28-374.
• Immunity scope. Section 28-375 immunity covers participation in the report and any subsequent judicial proceeding. The exception for "false statements of fact made with malicious intent" reinforces that good-faith reporting is protected even if the underlying allegations are not ultimately substantiated.
• Central Registry. Substantiated findings are entered into the Adult Protective Services Central Registry under § 28-376, which carries employment consequences for individuals working in caregiving roles. Subjects of reports have notice and appeal rights.
• Long-term care facility cases. For abuse, neglect, or exploitation occurring in a licensed facility, parallel notifications should be made to the Nebraska State Long-Term Care Ombudsman (Aging and Disability Resource Centers / Area Agencies on Aging) and to DHHS Public Health Division — Office of Long-Term Care Facilities Licensure for regulatory enforcement under Title 175 NAC.
• Financial exploitation. For suspected financial exploitation, also consider notification to the financial institution's elder-fraud unit (federally permitted under the Senior Safe Act, 12 U.S.C. § 3423), local law enforcement, and the Nebraska Attorney General's Consumer Protection Division.
• Criminal exposure of the perpetrator. Knowing abuse, neglect, or exploitation of a vulnerable adult is criminalized under Neb. Rev. Stat. § 28-386 and § 28-387, with penalties graded by harm.
• Confidentiality vs. HIPAA. Reports made to APS pursuant to mandatory-reporting laws are permitted disclosures under 45 C.F.R. § 164.512(b) and (c). A HIPAA covered entity may report without a separate authorization.

12. SOURCES AND REFERENCES

• Adult Protective Services Act, Neb. Rev. Stat. §§ 28-348 to 28-387 — https://nebraskalegislature.gov/laws/display_html.php?begin_section=28-348&end_section=28-387
• Neb. Rev. Stat. § 28-372 (mandatory reporting; toll-free hotline) — https://nebraskalegislature.gov/laws/statutes.php?statute=28-372
• Neb. Rev. Stat. § 28-375 (immunity) — https://nebraskalegislature.gov/laws/statutes.php?statute=28-375
• Neb. Rev. Stat. § 28-376 (Central Registry) — https://nebraskalegislature.gov/laws/statutes.php?statute=28-376
• Neb. Rev. Stat. § 28-386 (failure to report; penalty)
• DHHS Adult Protective Services — https://dhhs.ne.gov/Pages/Adult-Protective-Services.aspx
• DHHS Mandatory Reporting Regs — https://dhhs.ne.gov/licensure/Documents/MandatoryReportingRegs.pdf
• Nebraska APS Hotline — 1-800-652-1999 (24/7)
• Nebraska State Long-Term Care Ombudsman — https://dhhs.ne.gov/Pages/Aging-Ombudsman.aspx
• 45 C.F.R. § 164.512(b)–(c) (HIPAA permitted disclosures for victims of abuse) — https://www.ecfr.gov/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. If a vulnerable adult is in immediate danger, call 911. Mandatory reporters must report to the Nebraska APS hotline (1-800-652-1999) — this written narrative supplements but does not substitute for the required telephonic report. Have any written communication reviewed by counsel where retaliation, defamation, or HIPAA exposure is a concern.