Nevada Adult Protective Services Report — Abuse, Neglect, Exploitation, Isolation, or Abandonment of Older or Vulnerable Person

NEVADA ADULT PROTECTIVE SERVICES REPORT — OLDER OR VULNERABLE PERSON

TABLE OF CONTENTS

1. Reporter Identification
2. Mandatory-Reporter Status
3. Subject of the Report
4. Alleged Perpetrator(s)
5. Type of Maltreatment Alleged
6. Narrative of Observations
7. Imminent Danger and Safety Assessment
8. Witnesses and Other Sources
9. Prior Reports and Agency Involvement
10. Telephonic Report Confirmation
11. Reporter Verification and Signature
12. Confidentiality and Immunity Statement
13. Nevada Practice Notes
14. Sources and References

1. REPORTER IDENTIFICATION

2. MANDATORY-REPORTER STATUS

The reporter is a mandatory reporter under NRS 200.5093 and/or NRS 200.50935 by reason of one or more of the following categories (check all that apply):

• ☐ Physician, physician assistant, dentist, dental hygienist, chiropractor, optometrist, podiatric physician, medical examiner, resident, intern, professional or practical nurse, or psychiatrist (NRS 200.5093(4)(a))
• ☐ Psychologist, marriage and family therapist, clinical professional counselor, clinical alcohol and drug counselor, alcohol and drug counselor, music therapist, athletic trainer, or other professional counselor (NRS 200.5093(4)(a))
• ☐ Person who maintains or is employed by an agency to provide nursing in the home or by a facility or agency that provides care for older or vulnerable persons (NRS 200.5093(4)(b))
• ☐ Employee of the Department of Health and Human Services, including ADSD and DHCFP (NRS 200.5093(4)(c))
• ☐ Employee of a law enforcement agency, county or city detention or correctional facility, or fire-fighting agency (NRS 200.5093(4)(d) – (f))
• ☐ Coroner (NRS 200.5093(4)(g))
• ☐ Member of the clergy, practitioner of Christian Science, or religious healer, except as to communications protected by privilege (NRS 200.5093(4)(h))
• ☐ Person working in school or in a position that provides services to older or vulnerable persons (NRS 200.5093(4)(i))
• ☐ Attorney, unless the attorney has acquired the knowledge through privileged communications (NRS 200.5093(4)(j))
• ☐ Employee of the office of long-term care ombudsman (NRS 200.5093(4)(k))
• ☐ Person who maintains or is employed by a financial institution (NRS 200.5093(4)(l))
• ☐ Other (specify): [________________________________]
• ☐ Voluntary (non-mandatory) reporter — any person who knows or has reasonable cause to believe (NRS 200.5093(2))

3. SUBJECT OF THE REPORT

4. ALLEGED PERPETRATOR(S)

Complete one block per alleged perpetrator. If unknown, write "UNKNOWN."

Perpetrator 1:

Perpetrator 2 (if any):

5. TYPE OF MALTREATMENT ALLEGED

Check all that apply. Definitions are drawn from NRS 200.5092.

• ☐ Abuse — physical (willful and unjustified infliction of pain, injury, or mental anguish)
• ☐ Abuse — sexual (any unwanted sexual contact, including contact involving a person without capacity to consent)
• ☐ Abuse — emotional / psychological / verbal (willful infliction of mental anguish through threats, intimidation, humiliation)
• ☐ Neglect (failure of a person who has assumed legal responsibility, or contracted to provide care, to provide food, shelter, clothing, services, or medical care)
• ☐ Self-neglect (an older or vulnerable person living alone is unable to provide for personal needs and a substantial threat to health or safety exists)
• ☐ Exploitation (improper use, conversion, or management of money, assets, or property of an older or vulnerable person, or use of undue influence to convert or take possession)
• ☐ Isolation (willful preventing of an older or vulnerable person from receiving visitors, mail, or telephone calls, contrary to the wishes of the person)
• ☐ Abandonment (desertion or willful forsaking by someone with a duty of care)

6. NARRATIVE OF OBSERVATIONS

Describe specifically: what was observed; when; where; by whom; and what the subject reported. Use the subject's own words in quotation marks where possible. Attach photographs, screenshots, financial statements, or other documentation as exhibits. Avoid speculation; mark inferences clearly.

6.1. Date and time of incident or observation: [__/__/____] at [__:__] ☐ AM ☐ PM.

6.2. Location: [________________________________].

6.3. Direct observations:

[________________________________]

[________________________________]

[________________________________]

6.4. Statements by subject (verbatim where possible):

[________________________________]

6.5. Visible injuries / physical findings (location, size, color, appearance, age of bruising):

[________________________________]

6.6. Financial indicators (unexplained withdrawals, missing valuables, new powers of attorney, changes to beneficiary designations, suspicious transfers):

[________________________________]

6.7. Environmental conditions (cleanliness, food availability, working utilities, medication storage, access to phone):

[________________________________]

6.8. Documents / exhibits attached:

• ☐ Photographs (descriptions and date stamps): [________________________________]
• ☐ Bank statements / cancelled checks: [________________________________]
• ☐ Medical records / progress notes: [________________________________]
• ☐ Facility incident reports: [________________________________]
• ☐ Recordings / electronic messages: [________________________________]
• ☐ Other: [________________________________]

7. IMMINENT DANGER AND SAFETY ASSESSMENT

7.1. Is the subject in imminent danger of serious bodily harm or death? ☐ Yes ☐ No

7.2. Has 9-1-1 / law enforcement been called? ☐ Yes — agency: [____________]; case/event #: [____________] ☐ No

7.3. Is the subject currently safe at this moment? ☐ Yes ☐ No — explain: [________________________________]

7.4. Does the subject have decision-making capacity? ☐ Yes ☐ No ☐ Unknown / disputed

7.5. Is there a current power of attorney or guardian? ☐ Yes ☐ No ☐ Unknown — name and relationship: [________________________________]

7.6. Suggested immediate protective steps (for ADSD consideration):

[________________________________]

8. WITNESSES AND OTHER SOURCES

9. PRIOR REPORTS AND AGENCY INVOLVEMENT

• ☐ Prior APS report — date(s): [____________]; outcome: [____________]
• ☐ Law enforcement involvement — agency / case #: [____________]
• ☐ Long-Term Care Ombudsman involvement: [____________]
• ☐ Guardianship proceeding pending in: [____________] County, Nevada; case #: [____________]
• ☐ Civil proceeding (protective order, conservatorship, financial recovery): [____________]
• ☐ Licensing board complaint (medical, nursing, social work, financial): [____________]
• ☐ None known

10. TELEPHONIC REPORT CONFIRMATION

11. REPORTER VERIFICATION AND SIGNATURE

I declare under penalty of perjury under the laws of the State of Nevada that the foregoing report is true and correct to the best of my knowledge, information, and belief, and that I am submitting this report in good faith pursuant to NRS 200.5093 and/or NRS 200.50935.

[________________________________] Date: [__/__/____]

[REPORTER NAME / TITLE]

Subscribed and sworn to before me (if notarization required by recipient agency) this [____] day of [_______________], 20[____].

[________________________________]

Notary Public — State of Nevada

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

12. CONFIDENTIALITY AND IMMUNITY STATEMENT

Pursuant to NRS 200.5095, this report and any record made by ADSD in the course of investigation are confidential and may be disclosed only as authorized by statute.

Pursuant to NRS 200.5096, any person who in good faith causes, conducts, or otherwise participates in an investigation, or who reports information pursuant to NRS 200.5091 to 200.50995, is immune from civil or criminal liability arising from such conduct. Good faith is presumed.

Pursuant to NRS 200.5099(7) and (8), a person required to make a report who knowingly and willfully fails to do so is guilty of a misdemeanor; failure to report a violation that constitutes a sexual offense or that results in substantial bodily or mental harm is a gross misdemeanor.

13. NEVADA PRACTICE NOTES

• Definition of "older person." NRS 200.5092 defines an "older person" as a person who is 60 years of age or older. The federal Older Americans Act uses 60 as well.
• Definition of "vulnerable person." NRS 200.5092 defines a "vulnerable person" as a person 18 years of age or older who has a physical or mental impairment that substantially limits the person's ability to provide for personal needs or to protect rights and interests.
• Time limit — 24 hours. Mandatory reporters must report "as soon as reasonably practicable, but not later than 24 hours after there is reason to believe" maltreatment has occurred. NRS 200.5093(1).
• Investigation timeline. ADSD or law enforcement must begin an investigation within 3 working days of receiving the report (NRS 200.5093(3)) and complete the investigation within a reasonable time.
• Cross-reporting. A report alleging conduct that is also a crime must be cross-reported to local law enforcement. Conversely, law enforcement receiving an APS report must forward it to ADSD.
• Privileged communications. Attorney-client and clergy-penitent privileges remain enforceable; the duty to report does not abrogate them. NRS 200.5093(4)(h), (j).
• Financial-institution reporting. NRS 200.5093 specifically obligates banks, credit unions, and other financial institutions to report suspected exploitation. The Nevada SAFE Act and federal SAR-filing obligations may also apply.
• Long-Term Care Ombudsman coordination. When the subject resides in a licensed long-term care facility, simultaneously consider engaging the Nevada Long-Term Care Ombudsman (1-888-282-1155) for advocacy independent of regulatory enforcement.
• Self-neglect. Self-neglect by a competent adult presents difficult issues. ADSD intervention may be limited if the subject has capacity and refuses services; consider guardianship petition under NRS Chapter 159A in appropriate cases.
• Retaliation prohibited. A facility, employer, or person may not retaliate against a reporter; retaliation may give rise to civil and licensing remedies in addition to the criminal exposure of the underlying conduct.

14. SOURCES AND REFERENCES

• Nevada Aging and Disability Services Division — Adult Protective Services — https://adsd.nv.gov/Programs/Seniors/EPS/EPS_Prog/
• ADSD APS Statewide Hotline: 1-888-729-0571
• Nevada Long-Term Care Ombudsman Helpline: 1-888-282-1155
• NRS Chapter 200 (Crimes Against the Person, including elder/vulnerable adult abuse) — https://www.leg.state.nv.us/nrs/nrs-200.html
• NRS 200.5093 — https://www.leg.state.nv.us/nrs/nrs-200.html#NRS200Sec5093
• NRS 200.5096 (immunity) — https://www.leg.state.nv.us/nrs/nrs-200.html#NRS200Sec5096
• NRS 200.5099 (penalties) — https://www.leg.state.nv.us/nrs/nrs-200.html#NRS200Sec5099
• Nevada Legal Services — Financial Exploitation of Older Adults Guide — https://nevadalegalservices.org
• National Adult Protective Services Association — https://www.napsa-now.org
• Eldercare Locator (federal) — https://eldercare.acl.gov / 1-800-677-1116

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. The contents of this template are NOT a substitute for the immediate telephonic report Nevada law requires. Verify all citations and contact information against current ADSD publications. A Nevada-licensed attorney should review any report submitted in connection with litigation, employment, licensing, or guardianship matters.