Oregon Adult Protective Services Report — Mandatory Reporter

OREGON ADULT PROTECTIVE SERVICES REPORT — MANDATORY REPORTER

TABLE OF CONTENTS

1. Urgent Safety Notice
2. Reporter Information
3. Reporter Status and Mandatory-Reporter Basis
4. Vulnerable Adult / Alleged Victim Information
5. Alleged Abuser / Person of Concern
6. Type of Abuse Alleged
7. Detailed Narrative of Observations and Concerns
8. Prior Reports / Pattern
9. Witnesses and Collateral Sources
10. Evidence Preserved
11. Risk Assessment and Immediate Safety Steps Taken
12. Oral Report Documentation
13. Reporter Certification
14. Oregon Practice Notes
15. Sources and References

1. URGENT SAFETY NOTICE

If the alleged victim is in immediate danger of death or serious physical harm, STOP COMPLETING THIS FORM AND DIAL 911. After ensuring immediate safety, call the ODHS Statewide Abuse Reporting Hotline at 1-855-503-SAFE (1-855-503-7233) to make the oral report required by ORS 124.060 and 124.065.

2. REPORTER INFORMATION

3. REPORTER STATUS AND MANDATORY-REPORTER BASIS

3.1. Reporter is a "public or private official" acting in an official capacity within the meaning of ORS 124.050(7) and 124.060. Indicate basis (check all that apply):

• ☐ Physician (MD/DO)
• ☐ Nurse / Nurse Practitioner / CNA
• ☐ Emergency medical technician / Paramedic
• ☐ Dentist / Optometrist / Chiropractor
• ☐ Physical / Occupational / Speech therapist
• ☐ Pharmacist
• ☐ Mental-health professional / Psychologist / Counselor
• ☐ Licensed clinical social worker / MSW
• ☐ Hospital / clinic employee or volunteer
• ☐ Long-term care facility staff (nursing facility, RCF, ALF, memory care)
• ☐ Adult foster home provider / staff
• ☐ In-home care agency / homecare worker
• ☐ Hospice or home-health employee
• ☐ Clergy (subject to privilege under ORS 40.260)
• ☐ Attorney (subject to ORS 40.225 attorney-client privilege carve-out)
• ☐ Peace officer / Law enforcement
• ☐ Firefighter
• ☐ ODHS / OHA / DD Services / APD / AAA employee
• ☐ Long-Term Care Ombudsman / volunteer
• ☐ School employee
• ☐ Public guardian / conservator
• ☐ Court-appointed special advocate (CASA)
• ☐ Bank / financial institution employee (per ORS 124.110 financial-exploitation reporting)
• ☐ Legislator / public official
• ☐ Other public or private official: [________________________________]

3.2. Reporter has reasonable cause to believe abuse occurred based on (check all that apply):

• ☐ Direct observation
• ☐ Statements of the vulnerable adult
• ☐ Statements of a third party
• ☐ Medical findings
• ☐ Financial records
• ☐ Other: [________________________________]

4. VULNERABLE ADULT / ALLEGED VICTIM INFORMATION

4.1. Statutory Basis for Protected Status (check all that apply):

• ☐ Person 65 years of age or older (ORS 124.050(1) — "elderly person")
• ☐ Adult with a developmental disability
• ☐ Adult with a mental illness
• ☐ Adult with a physical disability who depends on others for assistance with ADLs

4.2. Cognitive Capacity: ☐ Capable ☐ Mild impairment ☐ Moderate impairment ☐ Severe impairment ☐ Unknown.

4.3. Communication Needs / Language / Accommodations: [________________________________]

4.4. Primary Caregiver(s): Name / relationship / contact: [________________________________]

4.5. Health Care Provider: [________________________________]

4.6. Existing Legal Documents: ☐ POA ☐ Conservatorship ☐ Guardianship ☐ Advance Directive ☐ POLST ☐ None known.

5. ALLEGED ABUSER / PERSON OF CONCERN

6. TYPE OF ABUSE ALLEGED

Check all that apply (statutory definitions in ORS 124.050 and 124.105):

• ☐ Physical abuse — assault, bodily injury, restraint, force.
• ☐ Sexual abuse — non-consensual sexual contact or exploitation.
• ☐ Verbal / psychological abuse — threats, intimidation, harassment, isolation.
• ☐ Neglect — failure of caregiver to provide food, clothing, shelter, hygiene, medical care, or supervision.
• ☐ Self-neglect — adult unable to meet own basic needs.
• ☐ Financial exploitation — wrongful taking, misappropriation, undue influence (ORS 124.110, 124.115).
• ☐ Abandonment — desertion by caregiver.
• ☐ Wrongful use or restraint — chemical or physical restraint without medical necessity.
• ☐ Involuntary seclusion.
• ☐ Theft / fraud / scam.
• ☐ Other: [________________________________]

7. DETAILED NARRATIVE OF OBSERVATIONS AND CONCERNS

7.1. Date(s) and Time(s) of Incident(s) or Observations: [________________________________]

7.2. Location(s): [________________________________]

7.3. Narrative. [________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]
[________________________________]

7.4. Direct Quotes from Victim (verbatim where possible): [________________________________]

7.5. Visible Injuries / Physical Findings: [________________________________]

7.6. Apparent Cognitive / Emotional State of Victim: [________________________________]

7.7. Environmental / Hygiene Conditions: [________________________________]

7.8. Financial Indicators (unusual transactions, missing funds, new beneficiary, undue influence): [________________________________]

8. PRIOR REPORTS / PATTERN

8.1. Is reporter aware of prior APS, law enforcement, or ombudsman reports involving this victim? ☐ Yes ☐ No ☐ Unknown.

8.2. If yes, summarize: [________________________________]

8.3. Pattern of escalation observed? [________________________________]

9. WITNESSES AND COLLATERAL SOURCES

10. EVIDENCE PRESERVED

• ☐ Photographs of injuries / environment (date-stamped)
• ☐ Medical records / progress notes
• ☐ Bank statements / canceled checks / deeds
• ☐ Text messages / voicemails / emails
• ☐ Video / audio recordings
• ☐ Care-plan or facility incident reports
• ☐ Other: [________________________________]

10.1. Chain-of-Custody Notes: [________________________________]

11. RISK ASSESSMENT AND IMMEDIATE SAFETY STEPS TAKEN

11.1. Imminent danger? ☐ Yes ☐ No.

11.2. 911 called? ☐ Yes (CAD/Incident #: [____________]) ☐ No.

11.3. Law enforcement notified? ☐ Yes — Agency: [____________] | Officer: [____________] | Case #: [____________] ☐ No.

11.4. Medical care obtained? ☐ Yes — Provider: [____________] ☐ No.

11.5. Steps reporter has taken to protect victim: [________________________________]

11.6. Recommended protective measures: ☐ Welfare check ☐ Removal from home/facility ☐ Restraining order under ORS 124.005-124.040 (Elderly Persons and Persons with Disabilities Abuse Prevention Act) ☐ Conservatorship petition ☐ Facility incident investigation ☐ Other: [____________]

12. ORAL REPORT DOCUMENTATION

Oregon law requires an immediate oral report (ORS 124.065). Document the oral report below:

13. REPORTER CERTIFICATION

I certify that I am a public or private official within the meaning of ORS 124.050(7) and 124.060, that I have reasonable cause to believe the abuse described in this report has occurred, and that the information set forth above is true and accurate to the best of my knowledge and belief, made in good faith pursuant to my mandatory reporting obligation under ORS 124.060.

I understand that I am entitled to civil and criminal immunity for this good-faith report under ORS 124.075, and that my identity is confidential under ORS 124.080 and may be disclosed only with my consent or by judicial process.

Date: [__/__/____]

[________________________________]

[REPORTER NAME]

Signature: [________________________________]

14. OREGON PRACTICE NOTES

• Hotline. ODHS Statewide Abuse Reporting Hotline: 1-855-503-SAFE (1-855-503-7233), 24 hours / 7 days. Online intake: https://www.oregon.gov/odhs/report-abuse/. For facility-based abuse, the report routes to APS or to the Office of the Long-Term Care Ombudsman as appropriate.
• Immediate oral report. ORS 124.065 requires an immediate oral report by telephone or in person to ODHS or to law enforcement in the county where the reporter is located. The written form does not substitute for the oral call.
• Who is a mandatory reporter. ORS 124.050(7) and 124.060 cover an extensive list of "public or private officials." When in doubt, report. Volunteer reporting is also encouraged and protected.
• Privilege carve-outs. Under ORS 124.060, attorney-client privilege under ORS 40.225 is preserved; psychotherapist-patient privilege is preserved as to communications received in a treatment context for that patient; clergy-penitent privilege under ORS 40.260 is preserved. Otherwise, evidentiary privileges do not excuse the reporting duty.
• Immunity. ORS 124.075 confers civil and criminal immunity for good-faith reports and for participating in resulting judicial proceedings.
• Confidentiality. ORS 124.080 makes the reporter's identity confidential, releasable only with the reporter's consent or by judicial process.
• Penalty for failure to report. ORS 124.990 makes failure to report a Class A violation. Professional discipline may also apply.
• Financial exploitation. ORS 124.100 to 124.140 create a private civil cause of action (with treble damages and attorney fees) for vulnerable persons subjected to financial abuse. Reporting under ORS 124.060 does not preclude civil suit.
• Restraining orders. The Elderly Persons and Persons with Disabilities Abuse Prevention Act (ORS 124.005 to 124.040) provides for ex parte and final restraining orders in circuit court — a powerful tool when immediate physical separation is needed.
• Long-term care facility abuse. When the alleged abuse occurred in a nursing facility, residential care facility, assisted living facility, memory care community, or adult foster home, also notify the Oregon Long-Term Care Ombudsman (1-800-522-2602) and consider a parallel complaint to OHA Health Care Regulation and Quality Improvement (for nursing facilities) or ODHS APD licensing (for community-based facilities).
• Investigation. APS must initiate an investigation per ORS 124.070 and OAR 411-020 within statutory timeframes. APS may coordinate with law enforcement, the local district attorney's elder-abuse multidisciplinary team (MDT), and licensing entities.

15. SOURCES AND REFERENCES

• ORS Chapter 124 (Abuse of Elderly Persons and Persons with Disabilities) — https://www.oregonlegislature.gov/bills_laws/ors/ors124.html
• ORS 124.050 (Definitions) — https://oregon.public.law/statutes/ors_124.050
• ORS 124.060 (Mandatory reporting) — https://oregon.public.law/statutes/ors_124.060
• ORS 124.065 (Method of reporting) — https://oregon.public.law/statutes/ors_124.065
• ORS 124.070 (Investigation duty) — https://oregon.public.law/statutes/ors_124.070
• ORS 124.075 (Immunity) — https://oregon.public.law/statutes/ors_124.075
• ORS 124.080 (Confidentiality) — https://oregon.public.law/statutes/ors_124.080
• ORS 124.090 / 124.990 (Penalty for failure to report)
• OAR 411-020-0020 (Reporting of Abuse and Self-Neglect) — https://oregon.public.law/rules/oar_411-020-0020
• ODHS Report Abuse — https://www.oregon.gov/odhs/report-abuse/
• Oregon Long-Term Care Ombudsman — https://www.oregon.gov/ltco/ ; 1-800-522-2602
• Oregon DOJ Elder Abuse — https://www.doj.state.or.us/oregon-department-of-justice/elder-abuse/
• Oregon State Bar — Elder Abuse Reporting Q&A — https://www.courts.oregon.gov/programs/jcip/EducationMaterials/Documents/ElderAbuseReportQA.pdf

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Mandatory reporters must comply with the immediate-oral-report obligation in ORS 124.065 and consult counsel for case-specific questions about privilege, scope, or downstream litigation. If a person is in immediate danger, call 911.