Tennessee Adult Protective Services (APS) Report of Suspected Abuse, Neglect, or Exploitation

TENNESSEE ADULT PROTECTIVE SERVICES (APS) REPORT

TABLE OF CONTENTS

1. Reporter Information
2. Subject Adult Information
3. Alleged Perpetrator Information
4. Type of Abuse, Neglect, or Exploitation
5. Narrative — Description of Concerns
6. Evidence and Witnesses
7. Risk Assessment and Immediate Safety
8. Prior Reports and Agency Involvement
9. Hotline Submission Record
10. Reporter Affidavit and Signature
11. Tennessee Practice Notes
12. Sources and References

1. REPORTER INFORMATION

2. SUBJECT ADULT INFORMATION

Definition of "Adult" under T.C.A. § 71-6-102: A person eighteen (18) years of age or older who, because of mental or physical dysfunction or advanced age, is unable to manage his or her own resources, carry out the activities of daily living, or protect himself or herself from neglect, hazardous or abusive situations without assistance from others, and who has no available, willing, and responsibly able person for assistance, OR who is the victim of self-neglect.

3. ALLEGED PERPETRATOR INFORMATION

4. TYPE OF ABUSE, NEGLECT, OR EXPLOITATION

Check all that apply (definitions per T.C.A. § 71-6-102):

☐ Physical abuse — infliction of physical pain, injury, or mental anguish, or unreasonable confinement.

☐ Sexual abuse — non-consensual sexual contact, exploitation, or assault.

☐ Emotional / psychological abuse — verbal abuse, threats, isolation, intimidation.

☐ Neglect (by caregiver) — failure to provide goods or services necessary to avoid physical harm, mental anguish, or mental illness.

☐ Self-neglect — adult's own conduct that threatens his or her health or safety due to inability to manage personal care.

☐ Financial exploitation — improper or illegal use of an adult's resources for another's profit or advantage. Includes:

• ☐ Theft / unauthorized withdrawals
• ☐ Forged checks or signatures
• ☐ Misuse of power of attorney / conservatorship
• ☐ Undue influence over deeds, wills, or beneficiary designations
• ☐ Telephone / internet / lottery / romance scams
• ☐ Identity theft
• ☐ Caregiver charging for services not rendered

☐ Abandonment — desertion of an adult by a caregiver who has assumed responsibility.

☐ Other: [____________________________________]

5. NARRATIVE — DESCRIPTION OF CONCERNS

Provide a chronological, factual account. Distinguish observation from inference. Use direct quotes where possible.

Date/time concerns first arose: [__/__/____] [__:__ AM/PM]

Source of information (☐ direct observation ☐ statement of subject adult ☐ statement of third party ☐ medical record ☐ financial record ☐ other):

[________________________________]

Observed injuries / physical findings (location, color, size, age of bruising; weight loss; pressure ulcers; poor hygiene; etc.):

[________________________________]

[________________________________]

[________________________________]

Statements made by the subject adult:

[________________________________]

[________________________________]

Statements made by alleged perpetrator or others:

[________________________________]

[________________________________]

Pattern / frequency / escalation:

[________________________________]

Financial indicators (if exploitation suspected):

• Recent unexplained withdrawals or transfers: [________________]
• New account signers / joint owners: [________________]
• Change in beneficiary / will / deed: [________________]
• Unpaid bills despite available funds: [________________]
• Missing valuables: [________________]

6. EVIDENCE AND WITNESSES

Witnesses:

7. RISK ASSESSMENT AND IMMEDIATE SAFETY

☐ Subject adult is in IMMEDIATE DANGER — 911 has been called. Law enforcement responding officer / case number: [________]

☐ Subject adult is currently safe but at risk if alleged perpetrator returns / regains access.

☐ Subject adult requires emergency medical care.

☐ Subject adult lacks food, medication, heat, or other essentials.

☐ Subject adult is isolated; alleged perpetrator controls communications.

☐ Subject adult has been removed to safe location: [____________]

Capacity concerns: ☐ Subject adult appears unable to consent to or refuse protective services. T.C.A. § 71-6-107 protective-services court order may be needed.

8. PRIOR REPORTS AND AGENCY INVOLVEMENT

☐ I have made prior APS reports concerning this adult. Date(s) / case number(s): [________]

☐ Other agencies involved: ☐ Law enforcement ☐ Long-Term Care Ombudsman ☐ TennCare ☐ Adult Day Care ☐ Hospital social work ☐ Veterans Affairs ☐ Bank fraud unit ☐ District Attorney ☐ Other: [________]

☐ Conservatorship / guardianship: ☐ None known ☐ Petition pending ☐ Conservator appointed: [name]

☐ Power of attorney known: ☐ None ☐ Yes — agent: [________]

9. HOTLINE SUBMISSION RECORD

10. REPORTER AFFIDAVIT AND SIGNATURE

I, [REPORTER NAME], state under penalty of perjury that:

1. I have reasonable cause to suspect that the subject adult has been or is being abused, neglected, or exploited as described above.

2. The information provided in this report is true, complete, and correct to the best of my knowledge and belief, and is based upon my personal observation, professional review, or information supplied by identified third parties.

3. I am submitting this report in good faith pursuant to T.C.A. § 71-6-103.

4. I understand that, pursuant to T.C.A. § 71-6-105, persons making good-faith reports are immune from civil and criminal liability and are protected from retaliatory employment action; and that pursuant to T.C.A. § 71-6-118, my identity is confidential and may be disclosed only by court order.

5. I understand that knowing failure to make a required report may constitute a Class A misdemeanor under T.C.A. § 71-6-117.

[________________________________]

[REPORTER NAME]

Date: [__/__/____]

11. TENNESSEE PRACTICE NOTES

• Universal reporter law. Tennessee's mandatory-reporting duty under T.C.A. § 71-6-103(b) extends to "any person" — not merely enumerated professionals. Lay reporters are equally protected and equally obligated.
• Statewide hotline. 1-888-APS-TENN / 1-888-277-8366 is staffed 24/7. The online portal at reportadultabuse.dhs.tn.gov accepts reports through the same intake system.
• Privilege abrogation. T.C.A. § 71-6-103(b)(2) overrides physician–patient, psychotherapist–patient, and other professional privileges except the attorney–client privilege. Clinicians cannot withhold a report citing privilege.
• Time to report. The statute requires "immediate" reporting. DHS interprets this to mean as soon as practicable, generally within 24 hours of forming reasonable suspicion. Do not delay to gather evidence.
• Investigation timelines. DHS is required to commence investigation promptly. Imminent-risk reports trigger a same-day or 24-hour response; standard reports a multi-day response. Investigators have authority to enter, interview, and review records.
• Court protective services. Where the adult lacks capacity to consent or refuse services, T.C.A. § 71-6-107 authorizes DHS to petition for emergency protective services order, including authority to remove the adult from a dangerous situation.
• Coordination with law enforcement. DHS shall notify law enforcement when a report involves abuse, neglect, or exploitation by another person. Criminal statutes (T.C.A. § 39-15-501 et seq. — abuse, neglect, or exploitation of a vulnerable adult) operate in parallel with APS civil protective services.
• Financial exploitation reporting by financial institutions. Tennessee broker-dealers, banks, and investment advisers have parallel reporting authority under T.C.A. § 45-2-1201 et seq. (Tennessee Senior Financial Protection Act) permitting transaction holds and reporting to APS.
• Long-term care facilities. When the subject adult resides in a nursing home, assisted-living facility, or home for the aged, the report should ALSO be made to the Long-Term Care Ombudsman (Tennessee Commission on Aging and Disability) and to the Tennessee Department of Health Health Care Facilities Division.
• Confidentiality of records. APS investigation records are confidential under T.C.A. § 71-6-118; release is restricted to specified parties and court orders.

12. SOURCES AND REFERENCES

• Tennessee Adult Protection Act, T.C.A. Title 71, Chapter 6, Part 1 — https://www.capitol.tn.gov
• T.C.A. § 71-6-103 (mandatory reporting) — https://law.justia.com/codes/tennessee/title-71/chapter-6/part-1/section-71-6-103/
• T.C.A. § 71-6-105 (immunity; protection from retaliation) — https://law.justia.com/codes/tennessee/title-71/chapter-6/part-1/section-71-6-105/
• T.C.A. § 71-6-118 (confidentiality) — https://law.justia.com/codes/tennessee/title-71/chapter-6/part-1/
• Tennessee DHS — Adult Protective Services — https://www.tn.gov/humanservices/adults/adult-protective-services.html
• Online APS report portal — https://reportadultabuse.dhs.tn.gov
• APS hotline: 1-888-APS-TENN / 1-888-277-8366 (24/7)
• Tenn. Comp. R. & Regs. Chapter 1240-05-12 (DHS APS rules) — https://publications.tnsosfiles.com
• Tennessee Senior Financial Protection Act, T.C.A. § 45-2-1201 et seq.
• Help4TN — Elder Abuse — https://www.help4tn.org/page/1455/elder-abuse
• National Adult Protective Services Association — https://www.napsa-now.org

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. The Tennessee Adult Protection Act creates immediate legal obligations to report. If you suspect abuse, neglect, or exploitation, call 1-888-277-8366 or 911 first; complete this form afterward as a record. An attorney licensed in Tennessee should be consulted for any related litigation or representation.