Oklahoma Adult Protective Services (APS) Report — Vulnerable Adult

OKLAHOMA ADULT PROTECTIVE SERVICES REPORT — VULNERABLE ADULT

Submitted under the Protective Services for Vulnerable Adults Act, 43A O.S. § 10-101 et seq.

1. URGENCY AND IMMEDIATE-DANGER FLAGS

If the vulnerable adult is in immediate danger, call 911 first and report to DHS by phone before completing the rest of this form.

2. REPORTER INFORMATION

3. VULNERABLE ADULT INFORMATION

3.1 Vulnerability Basis

Under 43A O.S. § 10-103, "vulnerable adult" means an individual age 18 or older who because of physical or mental disability, including persons with Alzheimer's disease or other dementias, is substantially impaired in the ability to provide adequately for the individual's own care or protection. Indicators present:

• ☐ Alzheimer's disease or other dementia
• ☐ Intellectual or developmental disability
• ☐ Serious mental illness
• ☐ Physical disability impairing self-care
• ☐ Stroke / TBI / neurological condition
• ☐ Frailty due to advanced age
• ☐ Substance-use disorder impairing self-care
• ☐ Bedbound / immobility
• ☐ Sensory impairment (vision / hearing)
• ☐ Other (specify): [________________________________]

3.2 Decision-Making Status

• ☐ Capacity intact (no guardianship)
• ☐ Limited guardianship of the person — Guardian: [________]
• ☐ Plenary guardianship of the person — Guardian: [________]
• ☐ Limited / plenary guardianship of the property — Guardian: [________]
• ☐ Power of attorney in effect — Agent: [________]
• ☐ Healthcare proxy / advance directive — Surrogate: [________]
• ☐ Representative payee for SS / VA — Payee: [________]

4. ALLEGED MALTREATMENT

Mark every category that applies. Provide narrative facts in Section 5.

• ☐ Abuse (physical injury or pain inflicted by other than accidental means; unreasonable confinement; sexual abuse; sexual exploitation)
• ☐ Neglect (failure of caretaker or self to provide food, clothing, shelter, medical care, supervision, or services necessary to maintain mental and physical health)
• ☐ Verbal abuse (use of words, sounds, or other communication to threaten, intimidate, harass, or humiliate)
• ☐ Exploitation / financial exploitation (unjust or improper use of resources, property, or person of a vulnerable adult for profit or advantage)
• ☐ Caretaker misconduct (act or omission by a paid or unpaid caretaker that endangers the vulnerable adult)
• ☐ Self-neglect (vulnerable adult is unable or refusing to obtain necessary care, with substantial risk to health or safety)
• ☐ Sexual abuse / sexual assault
• ☐ Suspicious death (per 43A O.S. § 10-104 reporting duty when death of a vulnerable adult appears to result from abuse, neglect, or exploitation)

5. NARRATIVE — FACTS OBSERVED OR REPORTED

Describe specifically and concretely what was observed or reported, when, and where. Use direct quotations where available. Do not editorialize. Identify sources of information.

5.1 What happened

[________________________________________________________________________________________]

5.2 When (date(s) and time(s))

[________________________________________________________________________________________]

5.3 Where (address, room number, or location within facility)

[________________________________________________________________________________________]

5.4 How (mechanism, means, sequence)

[________________________________________________________________________________________]

5.5 Observed injuries, conditions, or property losses

[________________________________________________________________________________________]

5.6 Statements of the vulnerable adult (verbatim where possible)

[________________________________________________________________________________________]

5.7 Statements of witnesses or third parties

[________________________________________________________________________________________]

5.8 Pattern / history (prior incidents known to reporter)

[________________________________________________________________________________________]

6. ALLEGED PERPETRATOR(S)

7. FINANCIAL EXPLOITATION DETAIL (complete if applicable)

8. EVIDENCE AND DOCUMENTATION ATTACHED OR AVAILABLE

• ☐ Photographs of injuries / living conditions (with date / metadata)
• ☐ Medical records / chart entries
• ☐ Incident reports
• ☐ Bank statements / cancelled checks / signature cards
• ☐ Power of attorney / trust / deed / contract
• ☐ Surveillance / body-cam / facility video
• ☐ Texts, voicemails, emails
• ☐ Care plan / MDS / facility assessment
• ☐ Statements from witnesses (signed where possible)
• ☐ Police report number: [________]
• ☐ Other: [________________________________]

9. ACTIONS ALREADY TAKEN

• ☐ 911 / law enforcement notified — Agency: [________] Report #: [________]
• ☐ DHS Hotline 1-800-522-3511 called — Intake #: [________]
• ☐ Vulnerable adult moved to safe location — Where: [________]
• ☐ Medical care obtained — Provider: [________]
• ☐ Long-Term Care Ombudsman notified (1-800-211-2116) — for facility cases
• ☐ Office of the Attorney General — Medicaid Fraud Control Unit notified — for facility-resident cases
• ☐ State licensing agency notified (OSDH, OBNDD, Insurance, Banking) — Agency: [________]
• ☐ Adult Protective Services file already open — APS Worker: [________]
• ☐ Guardianship petition filed or contemplated — Court / case: [________]

10. STATUTORY ACKNOWLEDGMENTS

The reporter acknowledges and certifies under 43A O.S. § 10-104:

• ☐ This report is made in good faith and based on facts known to the reporter.
• ☐ The reporter understands that good-faith reporters have civil and criminal immunity.
• ☐ The reporter understands that knowingly making a false report is a misdemeanor.
• ☐ The reporter understands that knowingly and willfully failing to report when required is a misdemeanor.
• ☐ The reporter understands that retaliation by an employer for making a report is prohibited and may give rise to attorney-fee liability.
• ☐ The reporter understands that pertinent health information may be disclosed to DHS for purposes of investigation under 43A O.S. § 10-104(F) without violating HIPAA.

[________________________________]

[REPORTER NAME]

Date: [__/__/____] at [__:__]

11. INTERNAL ROUTING (FOR REPORTER'S RECORDS)

12. OKLAHOMA PRACTICE NOTES

• Reporter's standard. "Reasonable cause to believe" — not "proof beyond a reasonable doubt." Investigation is the role of DHS APS and law enforcement, not the reporter. Err on the side of reporting.
• Time of report. "As soon as the person is aware of the situation" (43A O.S. § 10-104). Document the time you became aware and the time you reported.
• Confidentiality. Identity of the reporter is confidential under 43A O.S. § 10-108. APS records are confidential and not part of the public record, with limited statutory exceptions for law enforcement, courts, and authorized agencies.
• Immunity is broad but conditioned on good faith. A knowingly false report loses immunity and is a misdemeanor.
• Retaliation. No employer may terminate, demote, or otherwise sanction an employee for making or cooperating with a report. The court may award reasonable attorney fees against violating employers.
• HIPAA interplay. 45 C.F.R. § 164.512(c) permits disclosure of protected health information to a public-health authority or other government authority authorized to receive reports of adult abuse, neglect, or domestic violence. Documenting the statutory basis in the chart protects the disclosure.
• Facility-based reports. When the vulnerable adult is in a nursing facility, residential care, assisted living, or DD home, also notify the Long-Term Care Ombudsman (1-800-211-2116) and OSDH Complaints (1-800-747-8419 or [email protected]). Medicaid Fraud Control Unit (Office of the Attorney General) handles abuse and neglect of recipients in Medicaid-funded facilities.
• Suspicious deaths. Deaths of vulnerable adults that appear to result from abuse, neglect, or exploitation are separately reportable to DHS, the medical examiner, and law enforcement.
• Court-ordered protective services. When the vulnerable adult lacks capacity to consent, DHS may petition under 43A O.S. § 10-105 for emergency protective services and short-term placement; counsel may need to coordinate with DHS.
• Document retention. Retain a copy of this report and the routing log in a secure, access-restricted file. Do not place identifying reporter information in the resident's medical chart absent statutory or facility-policy basis.

13. SOURCES AND REFERENCES

• 43A O.S. § 10-101 et seq. (Protective Services for Vulnerable Adults Act) — https://www.oklegislature.gov/
• 43A O.S. § 10-104 (Persons required to report; immunity; penalties) — https://law.justia.com/codes/oklahoma/title-43a/section-43a-10-104v2/
• Okla. Admin. Code Title 340, Chapter 5 (DHS APS — Maltreatment Allegations) — https://oklahoma.gov/okdhs/library/policy.html
• DHS Adult Protective Services — https://oklahoma.gov/okdhs/services/cap/aps.html
• DHS Statewide Abuse Hotline 1-800-522-3511 / Online Reporting Portal — https://www.ourokdhs.org/s/reportabuse
• DHS Hotlines page — https://oklahoma.gov/okdhs/contact-us/dhshotlines.html
• Long-Term Care Ombudsman (1-800-211-2116) — https://oklahoma.gov/okdhs/contact-us/asdhome.html
• OSDH Long-Term Care Complaints (1-800-747-8419) — https://oklahoma.gov/health/services/licensing-inspections/medical-facilities-service/complaints-and-enforcement-division.html
• Oklahoma Attorney General — Medicaid Fraud Control Unit — https://oklahoma.gov/oag.html
• Legal Aid Services of Oklahoma — Adult Protective Services overview — https://oklaw.org/organization/adult-protective-services
• 45 C.F.R. § 164.512(c) (HIPAA disclosure to authorities receiving reports of adult abuse, neglect, or domestic violence)

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Mandatory reporting obligations are statutory and time-sensitive. Call 1-800-522-3511 (or 911 if there is immediate danger) before relying on any written form. An attorney licensed in Oklahoma must review and customize this document before use in litigation, internal compliance, or external reporting beyond the basic Hotline call.