New Hampshire Adult Protective Services (APS) Report
NEW HAMPSHIRE ADULT PROTECTIVE SERVICES (APS) REPORT — VULNERABLE ADULT
TABLE OF CONTENTS
- Cover Sheet — How and When This Report Was Made
- Reporter Information
- Vulnerable Adult Information
- Alleged Perpetrator Information
- Type of Maltreatment Alleged
- Detailed Narrative of Concerns
- Witnesses and Supporting Evidence
- Risk Factors and Immediate Safety Concerns
- Other Agencies Notified
- Reporter Certification and Statutory Acknowledgments
- New Hampshire Practice Notes
- Sources and References
1. COVER SHEET — HOW AND WHEN THIS REPORT WAS MADE
To: Bureau of Elderly and Adult Services (BEAS), Adult Protective Services Program
New Hampshire Department of Health and Human Services
129 Pleasant Street, Concord, NH 03301
Re: Suspected Abuse / Neglect / Self-Neglect / Exploitation of a Vulnerable Adult — RSA 161-F:46
| Item | Entry |
|---|---|
| Date of this written report | [__/__/____] |
| Date and time oral report was first made | [__/__/____] at [___] ☐ a.m. ☐ p.m. |
| Method of oral report | ☐ BEAS 1-800-949-0470 ☐ BEAS (603) 271-7014 ☐ Local police: [___] ☐ Sheriff: [___] ☐ LTC Ombudsman 1-800-442-5640 |
| Receiver of oral report (name / badge #) | [________________________________] |
| BEAS intake / case number (if assigned) | [________________________________] |
| Reporter requests anonymity? | ☐ Yes ☐ No (Note: reporter identity is confidential under RSA 161-F:55 regardless.) |
2. REPORTER INFORMATION
2.1. Reporter.
| Field | Entry |
|---|---|
| Full legal name | [________________________________] |
| Title / occupation | [________________________________] |
| Employer / agency | [________________________________] |
| Mandatory reporter category | ☐ Physician / Nurse / Health professional ☐ Social worker ☐ Clergy ☐ Law enforcement ☐ Other adult |
| Work address | [________________________________] |
| Work telephone | [________________________________] |
| Mobile / preferred number | [________________________________] |
| [________________________________] | |
| Best times to be contacted | [________________________________] |
2.2. Relationship of reporter to the vulnerable adult.
[________________________________]
2.3. How reporter learned of the suspected maltreatment.
[________________________________]
[________________________________]
3. VULNERABLE ADULT INFORMATION
3.1. Identity.
| Field | Entry |
|---|---|
| Full legal name | [________________________________] |
| Also known as / nicknames | [________________________________] |
| Date of birth | [__/__/____] |
| Sex / gender | [___] |
| Race / ethnicity (optional) | [___] |
| Primary language | [___] |
| Communication needs / accommodations | [________________________________] |
3.2. Current location.
| Field | Entry |
|---|---|
| Street address | [________________________________] |
| City, State, Zip | [________________________________] |
| Type of setting | ☐ Own home ☐ Family member's home ☐ Assisted living ☐ Nursing facility ☐ Hospital ☐ Homeless ☐ Other: [___] |
| Facility name (if any) | [________________________________] |
| Telephone (if reachable) | [________________________________] |
| Best access route / safety considerations for an APS visit | [________________________________] |
3.3. Vulnerability — basis for "vulnerable adult" status under RSA 161-F:43. Indicate any condition that impairs the adult's ability to meet basic needs or protect against abuse, neglect, or exploitation:
- ☐ Age 60 or older with functional impairment
- ☐ Cognitive impairment / dementia / Alzheimer's disease
- ☐ Mental illness
- ☐ Intellectual or developmental disability
- ☐ Physical disability requiring assistance with ADLs
- ☐ Serious medical condition: [___]
- ☐ Other: [________________________________]
3.4. Caregivers / Legal status.
| Item | Entry |
|---|---|
| Primary caregiver (name, relationship, contact) | [________________________________] |
| Power of Attorney / Conservator / Guardian | ☐ None known ☐ POA: [___] ☐ Conservator: [___] ☐ Guardian: [___] |
| Recent hospitalizations or ED visits | [________________________________] |
4. ALLEGED PERPETRATOR INFORMATION
(Complete one block per alleged perpetrator. Attach additional sheets if more than two.)
4.1. Alleged Perpetrator #1.
| Field | Entry |
|---|---|
| Name | [________________________________] |
| Relationship to vulnerable adult | [________________________________] |
| Address | [________________________________] |
| Telephone | [________________________________] |
| Date of birth (if known) | [__/__/____] |
| Lives with vulnerable adult? | ☐ Yes ☐ No ☐ Unknown |
| Has access to finances / accounts? | ☐ Yes ☐ No ☐ Unknown |
| Holds POA / fiduciary role? | ☐ Yes ☐ No ☐ Unknown |
| Known weapons in the home? | ☐ Yes ☐ No ☐ Unknown |
| Known history of violence or substance abuse? | [________________________________] |
4.2. Alleged Perpetrator #2 (if any).
| Field | Entry |
|---|---|
| Name | [________________________________] |
| Relationship | [________________________________] |
| Address | [________________________________] |
| Telephone | [________________________________] |
| Other relevant info | [________________________________] |
5. TYPE OF MALTREATMENT ALLEGED
Check all that apply. RSA 161-F:43 defines each below.
- ☐ Physical abuse — striking, slapping, restraining, force-feeding, inappropriate use of medication or restraints.
- ☐ Sexual abuse / assault — non-consensual sexual contact of any kind.
- ☐ Emotional / psychological abuse — threats, humiliation, intimidation, isolation, harassment.
- ☐ Neglect by caregiver — failure of a person responsible for care to provide food, water, hygiene, shelter, supervision, medical care, or to protect from harm.
- ☐ Self-neglect — vulnerable adult is unable or unwilling to perform essential self-care, resulting in serious threat to health or safety.
- ☐ Financial exploitation — improper use of funds, property, or assets; theft; coercion; misuse of POA; identity theft; predatory lending; undue influence on transfers, deeds, or accounts.
- ☐ Abandonment — desertion by a person who has assumed responsibility for care.
- ☐ Hazardous living conditions — squalor, lack of utilities, structural hazards, infestation, fire risk.
6. DETAILED NARRATIVE OF CONCERNS
6.1. Date / period of suspected maltreatment. From [__/__/____] to [__/__/____] (or ongoing).
6.2. Location of incident(s). [________________________________]
6.3. Specific observations (use objective, factual language; record direct quotes when possible).
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]
6.4. Physical findings (injuries, marks, weight loss, dehydration, pressure sores, hygiene issues, medication errors). Note location, size, color, and stage of any injury:
[________________________________]
[________________________________]
6.5. Statements made by the vulnerable adult (verbatim where possible; note demeanor, capacity, coherence):
[________________________________]
[________________________________]
6.6. Statements made by the alleged perpetrator(s):
[________________________________]
6.7. Financial indicators (if exploitation suspected): unusual withdrawals, missing checks, new joint owners on accounts, recent power of attorney, deed transfer, isolation from family, sudden inability to pay routine bills:
[________________________________]
[________________________________]
7. WITNESSES AND SUPPORTING EVIDENCE
7.1. Witnesses.
| Name | Relationship | Telephone / Address | Knowledge / Observations |
|---|---|---|---|
| [___] | [___] | [___] | [___] |
| [___] | [___] | [___] | [___] |
| [___] | [___] | [___] | [___] |
7.2. Documentary / physical evidence available (check all):
- ☐ Photographs of injuries or living conditions (attached / available)
- ☐ Medical records / chart notes
- ☐ Pharmacy / medication administration records
- ☐ Bank statements, canceled checks, account histories
- ☐ Power of Attorney, deed, or trust documents
- ☐ Email, text messages, voicemail recordings
- ☐ Police reports / 911 recordings
- ☐ Body-cam / facility video
- ☐ Other: [________________________________]
8. RISK FACTORS AND IMMEDIATE SAFETY CONCERNS
8.1. Imminent danger? ☐ Yes ☐ No
If yes, describe and confirm 911 / law enforcement has been contacted: [________________________________]
8.2. Risk factors present (check all):
- ☐ Vulnerable adult lives alone with no support network
- ☐ Alleged perpetrator has unrestricted access
- ☐ Alleged perpetrator is sole caregiver
- ☐ Alleged perpetrator controls finances
- ☐ Alleged perpetrator has substance abuse / mental health history
- ☐ History of domestic violence
- ☐ Cognitive impairment limits self-protection
- ☐ Recent change in legal documents (POA, will, deed)
- ☐ Vulnerable adult has been isolated from family / friends
- ☐ Weapons in home
- ☐ Other: [________________________________]
8.3. Recommended immediate action by APS:
[________________________________]
9. OTHER AGENCIES NOTIFIED
| Agency | Contact / Person | Date Notified |
|---|---|---|
| Local law enforcement (911) | [___] | [__/__/____] |
| County sheriff | [___] | [__/__/____] |
| Long-Term Care Ombudsman (if facility) | 1-800-442-5640 | [__/__/____] |
| DHHS Health Facilities Administration (licensing) | [___] | [__/__/____] |
| Treating physician / hospital | [___] | [__/__/____] |
| Adult's POA / guardian / family | [___] | [__/__/____] |
| Other | [___] | [__/__/____] |
10. REPORTER CERTIFICATION AND STATUTORY ACKNOWLEDGMENTS
10.1. Good-faith certification. I, the undersigned, in good faith report or cause to be reported information that I have reason to suspect indicates that a vulnerable adult has been subjected to abuse, neglect, self-neglect, exploitation, or hazardous living conditions, or is in need of protective services, pursuant to RSA 161-F:46.
10.2. Statutory immunity. Pursuant to RSA 161-F:47, persons participating in good faith in the making of a report, providing information, or following a reporting protocol developed jointly with the Department, or who in good faith investigate the report, administer the registry, or participate in any judicial or administrative proceeding resulting from that report, are immune from civil and criminal liability that might otherwise be incurred or imposed.
10.3. Penalty for failure to report or false reporting. I acknowledge that knowing failure to report under RSA 161-F:46 or knowingly making a false report is a misdemeanor under RSA 161-F:50.
10.4. Confidentiality. I understand that this report and the identity of the reporter are confidential under RSA 161-F:55, with limited disclosure exceptions.
10.5. Signature.
[________________________________]
[REPORTER NAME] — Date: [__/__/____]
(Optional notarization for written report transmitted by mail)
State of New Hampshire, County of [___]:
Subscribed and sworn before me on [__/__/____].
[________________________________]
Justice of the Peace / Notary Public — Commission expires: [__/__/____]
11. NEW HAMPSHIRE PRACTICE NOTES
- Universal mandatory reporting. RSA 161-F:46 imposes the duty on "any person." Every adult in New Hampshire is a mandated reporter. There is no professional-only limitation.
- Immediate oral report required. The statute requires an oral report "immediately" upon forming a reasonable suspicion. Do NOT wait to compile a written form. Use 1-800-949-0470 during business hours; after hours, report to local police or county sheriff. If the alleged victim is a resident of a nursing facility or assisted-living facility, also notify the Office of the Long-Term Care Ombudsman at 1-800-442-5640.
- Vulnerable adult definition. RSA 161-F:43 defines a "vulnerable adult" broadly to include any person 18 years of age or older who has a physical, mental, or other impairment that limits the ability to manage their own affairs or to protect themselves from abuse, neglect, or exploitation.
- Self-neglect is reportable. Unlike some state regimes, NH expressly covers self-neglect within RSA 161-F.
- Penalties for failure to report. RSA 161-F:50 makes knowing failure to report a misdemeanor. Knowingly false reporting is also a misdemeanor.
- Investigation. Under RSA 161-F:49, BEAS APS must initiate an investigation within statutorily-required timeframes set out in He-E 701. Emergency cases warrant same-day response.
- Confidentiality. RSA 161-F:55 protects reporter identity and case records. Disclosure is generally limited to law-enforcement, prosecutorial, judicial, or specifically authorized purposes.
- Criminal coordination. Cases involving suspected criminal abuse, sexual assault, or theft may be referred for prosecution under RSA 631:8 (abuse of an elderly, disabled, or impaired adult) and the general Title LXII Criminal Code.
- Court-ordered protective services. If the vulnerable adult lacks capacity and is unwilling to accept services, BEAS may petition the probate division of the Circuit Court for emergency or guardianship relief under RSA 464-A.
12. SOURCES AND REFERENCES
- RSA Chapter 161-F (Elderly and Adult Services) — https://www.gencourt.state.nh.us/rsa/html/xii/161-f/161-f-mrg.htm
- RSA 161-F:46 (Reports of Adult Abuse; Investigations) — https://gc.nh.gov/rsa/html/XII/161-F/161-F-46.htm
- RSA 161-F:47 (Immunity From Liability) — https://law.justia.com/codes/new-hampshire/title-xii/chapter-161-f/section-161-f-47/
- N.H. Admin. Code He-E 701 — https://gc.nh.gov/rules/state_agencies/he-e700.html
- BEAS Adult Abuse Reporting (DHHS) — https://www.dhhs.nh.gov/report-concern/adult-abuse
- BEAS Form 3650 (statutory reference document) — https://www.dhhs.nh.gov/sites/g/files/ehbemt476/files/documents2/beas-form-3650.pdf
- DHHS Health Officer Manual — Reporting Abuse and Neglect — https://www.dhhs.nh.gov/sites/g/files/ehbemt476/files/documents/2021-11/holu-reporting-neglect-and-abuse.pdf
- Long-Term Care Ombudsman — https://www.dhhs.nh.gov/about-dhhs/long-term-care-ombudsman
- BEAS APS Hotline: 1-800-949-0470 (in-state) | (603) 271-7014
- LTC Ombudsman: 1-800-442-5640 (in-state) | (603) 271-4375
- Emergency: 911
Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Mandatory reporters must report orally and immediately upon reasonable suspicion. Verify current statutory text and BEAS contact numbers on dhhs.nh.gov and gencourt.state.nh.us before relying on this form.
About This Template
Elder law covers the legal needs that come with aging: planning for long-term care costs, protecting assets from being wiped out by a nursing home stay, handling incapacity, and responding to elder abuse or financial exploitation. The paperwork often has to coordinate with Medicaid rules, tax treatment, and state guardianship requirements, which is why small mistakes can cost a family a great deal of money or control over decisions.
Important Notice
This template is provided for informational purposes. It is not legal advice. We recommend having an attorney review any legal document before signing, especially for high-value or complex matters.
Last updated: May 2026