Utah Adult Protective Services Report — Vulnerable Adult Abuse, Neglect, or Exploitation
UTAH ADULT PROTECTIVE SERVICES REPORT — VULNERABLE ADULT ABUSE, NEGLECT, OR EXPLOITATION
TABLE OF CONTENTS
- Emergency Notice and Filing Instructions
- Reporter Identification
- Vulnerable Adult Identification
- Alleged Perpetrator Identification
- Type of Abuse, Neglect, or Exploitation Alleged
- Narrative of Observations and Bases for Report
- Documentary, Photographic, and Witness Evidence
- Immediate Risk Assessment
- Coordinated Notifications
- Statutory Authority and Mandatory-Reporting Compliance
- Reporter Affirmation, Immunity, and Confidentiality
- Signature, Verification, and Certificate of Transmission
- Utah Practice Notes
- Sources and References
1. EMERGENCY NOTICE AND FILING INSTRUCTIONS
IF THE VULNERABLE ADULT IS IN IMMEDIATE DANGER, CALL 911 BEFORE COMPLETING THIS FORM.
Statewide APS Hotline: 1-800-371-7897 (Monday – Friday, 8:00 a.m. – 5:00 p.m. MT)
Online Intake (24/7): https://daas.utah.gov/adult-protective-services
Mailing Address (Salt Lake / Statewide Intake):
Utah DHHS — Division of Aging and Adult Services
Adult Protective Services
Multi-Agency State Office Building
195 North 1950 West
Salt Lake City, Utah 84116
Health Facility Licensing complaint line (for facility-based incidents): (801) 890-2007
Time limit: Reports must be made immediately upon forming reason to believe abuse, neglect, or exploitation has occurred. Utah Code § 26B-6-205.
2. REPORTER IDENTIFICATION
| Field | Detail |
|---|---|
| Reporter Full Name | [________________________________] |
| Title / Profession | [________________________________] |
| Mandatory Reporter Category | ☐ Healthcare provider ☐ Mental-health provider ☐ Social worker ☐ Law enforcement ☐ Clergy (subject to privilege) ☐ Long-term-care employee ☐ Bank / financial-institution employee ☐ Other professional ☐ Concerned citizen |
| Employer / Agency | [________________________________] |
| Business Address | [________________________________] |
| Direct Phone | [___-___-____] |
| [________________________________] | |
| Relationship to Vulnerable Adult | [________________________________] |
| Anonymous Reporting Requested | ☐ Yes ☐ No |
3. VULNERABLE ADULT IDENTIFICATION
| Field | Detail |
|---|---|
| Full Legal Name | [________________________________] |
| Also Known As | [________________________________] |
| Date of Birth | [__/__/____] |
| Age | [____] |
| Sex / Gender | [________________________________] |
| Primary Language | [________________________________] |
| Current Address (where reside) | [________________________________] |
| Type of residence | ☐ Private home ☐ Apartment ☐ Family member's home ☐ Assisted living ☐ Skilled-nursing facility ☐ Hospital ☐ Group home ☐ Homeless / unknown |
| Telephone | [___-___-____] |
| Mobility / Communication limitations | [________________________________] |
| Known disabilities or diagnoses | [________________________________] |
| Cognitive status (e.g., dementia stage) | [________________________________] |
| Primary physician / clinic | [________________________________] |
| Health-care agent / POA / Guardian | [________________________________] |
| Family / next of kin | [________________________________] |
3.1 "Vulnerable Adult" Determination
Per Utah Code § 26B-6-201, a "vulnerable adult" is an elder adult (age 65 or older) or an adult age eighteen (18) or older who has a mental or physical impairment that substantially affects the person's ability to (a) provide personal protection, (b) provide necessities such as food, shelter, clothing, or medical or other health care, (c) obtain services necessary for health, safety, or welfare, (d) carry out the activities of daily living, (e) manage the adult's own resources, or (f) comprehend the nature and consequences of remaining in a situation of abuse, neglect, or exploitation.
The reporter believes the individual is a vulnerable adult because: [____________________________________________________________]
4. ALLEGED PERPETRATOR IDENTIFICATION
| Field | Detail |
|---|---|
| Full Name | [________________________________] |
| Also Known As | [________________________________] |
| Relationship to Vulnerable Adult | ☐ Spouse / partner ☐ Adult child ☐ Other relative ☐ Caregiver / aide ☐ Facility staff ☐ Roommate ☐ Neighbor ☐ Friend / acquaintance ☐ Stranger ☐ Power-of-attorney agent ☐ Trustee / fiduciary ☐ Unknown |
| Date of Birth (if known) | [__/__/____] |
| Address | [________________________________] |
| Telephone | [___-___-____] |
| Employer (if facility-based) | [________________________________] |
| Occupational license # (if any) | [________________________________] |
| Lives with vulnerable adult? | ☐ Yes ☐ No |
| Has access to vulnerable adult's finances? | ☐ Yes ☐ No ☐ Unknown |
| History of violence / criminal record (if known) | [________________________________] |
5. TYPE OF ABUSE, NEGLECT, OR EXPLOITATION ALLEGED
Check all that apply. Definitions follow Utah Code § 26B-6-201.
- ☐ Physical abuse — knowing or intentional infliction of physical injury, unreasonable confinement, or use of physical or chemical restraint without consent.
- ☐ Emotional / psychological abuse — intentional verbal or nonverbal conduct that results in fear, mental anguish, or emotional distress (threats, intimidation, isolation, humiliation).
- ☐ Sexual abuse / sexual exploitation — non-consensual sexual contact, sexual offense as defined in Title 76, Chapter 5, or coerced sexual conduct involving a vulnerable adult who lacks capacity to consent.
- ☐ Caretaker neglect — failure of a caretaker to provide food, clothing, shelter, supervision, medical care, or other essentials to the extent necessary to maintain the vulnerable adult's physical or mental health.
- ☐ Self-neglect — vulnerable adult's own failure to provide necessary food, water, shelter, clothing, medical care, or other essentials due to mental or physical impairment.
- ☐ Abandonment — desertion of the vulnerable adult by a caretaker without making reasonable arrangements for continued care.
- ☐ Financial exploitation — wrongful use, withholding, or appropriation of a vulnerable adult's funds, property, or resources, including:
- ☐ unauthorized withdrawals or transfers;
- ☐ misuse of power of attorney, conservatorship, or trustee position;
- ☐ undue influence to convey property, sign contracts, or amend estate plan;
- ☐ deceptive sales, scams, or telemarketing fraud;
- ☐ theft of identity, Social Security or Medicare benefits, or VA benefits;
- ☐ misuse of joint accounts;
- ☐ failure to use the vulnerable adult's funds for the vulnerable adult's benefit (e.g., representative payee misuse).
- ☐ Medication abuse / chemical restraint — administration of medication for the purpose of restraining behavior rather than treatment.
- ☐ Other: [________________________________]
6. NARRATIVE OF OBSERVATIONS AND BASES FOR REPORT
6.1 Date, Time, and Location of First Observation
Date observed: [__/__/____] Time: [__:__ ☐ AM ☐ PM]
Location: [________________________________]
6.2 Detailed Narrative
[NARRATIVE — describe the conduct, statements, injuries, environment, and circumstances giving rise to the report. Include dates, locations, witnesses, and direct quotations where possible. Continue on attached pages as necessary.]
6.3 Observed Indicators (check all observed)
Physical
- ☐ Bruising in unusual or multiple stages of healing
- ☐ Lacerations, burns, fractures, abrasions
- ☐ Pressure injuries / bedsores (Stage [___])
- ☐ Dehydration, malnutrition, sudden weight loss
- ☐ Poor hygiene, soiled clothing, fecal/urine odor
- ☐ Restraint marks (wrist, ankle, waist)
- ☐ Unexplained sexually transmitted infection
- ☐ Unattended medical needs / missed medication doses
Behavioral / Emotional
- ☐ Sudden withdrawal or fearfulness
- ☐ Refuses to speak in caretaker's presence
- ☐ Disorientation atypical for prior baseline
- ☐ Sudden depression, anxiety, agitation
- ☐ Statements of being hit, threatened, or "punished"
- ☐ Sudden changes in sleeping or eating
Environmental
- ☐ Unsafe or unsanitary living conditions
- ☐ No food in home, utilities disconnected
- ☐ Hazardous home (no heat, vermin, animal feces)
- ☐ Locked in / unable to leave
- ☐ Caretaker controls all communication
Financial
- ☐ Unusual large withdrawals or transfers
- ☐ Newly added joint account holders
- ☐ Sudden change of POA / will / beneficiary
- ☐ Property transfers below fair market value
- ☐ Missing valuables or checks
- ☐ Unpaid bills despite adequate income
- ☐ Caretaker controlling all finances
- ☐ Patterns consistent with telemarketing or romance scam
6.4 Statements by the Vulnerable Adult
Direct statements (verbatim where possible): [________________________________________________]
Date / Time / Witnesses to statement: [________________________________]
6.5 Statements by Third Parties
Witness 1 — Name / Statement / Date: [________________________________]
Witness 2 — Name / Statement / Date: [________________________________]
7. DOCUMENTARY, PHOTOGRAPHIC, AND WITNESS EVIDENCE
| Item | Description | Date | Custodian |
|---|---|---|---|
| Photograph(s) of injury / environment | [___] | [__/__/____] | [___] |
| Medical records / discharge summary | [___] | [__/__/____] | [___] |
| Bank statements / transaction history | [___] | [__/__/____] | [___] |
| POA / trust / will / deed | [___] | [__/__/____] | [___] |
| Text messages / emails / voicemails | [___] | [__/__/____] | [___] |
| Surveillance / doorbell-camera footage | [___] | [__/__/____] | [___] |
| Police / EMS / hospital incident report | [___] | [__/__/____] | [___] |
| Other | [___] | [__/__/____] | [___] |
8. IMMEDIATE RISK ASSESSMENT
8.1. Is the vulnerable adult in immediate physical danger? ☐ Yes ☐ No ☐ Unknown
8.2. Does the vulnerable adult have access to needed medical care, food, water, and medication? ☐ Yes ☐ No
8.3. Is the alleged perpetrator currently with the vulnerable adult or has continuing access? ☐ Yes ☐ No
8.4. Does the vulnerable adult have capacity to consent to or refuse protective services? ☐ Has capacity ☐ Lacks capacity ☐ Capacity uncertain
8.5. Is there a pending hospital discharge, lease termination, eviction, or facility transfer? ☐ Yes ☐ No Date: [__/__/____]
8.6. Does the vulnerable adult have safe alternative housing, family support, or financial resources for short-term protection? ☐ Yes ☐ No
8.7. Recommended immediate protective measures: [________________________________________________]
9. COORDINATED NOTIFICATIONS
Check each agency notified:
- ☐ Adult Protective Services (DAAS) — 1-800-371-7897 — Date / Time: [__/__/____ __:__]; Intake # / Reference: [___]; Intake worker: [___]
- ☐ Local law enforcement — Agency: [___]; Officer / case #: [___]; Date: [__/__/____]
- ☐ 911 (immediate danger) — Date / Time: [__/__/____ __:__]
- ☐ DHHS Division of Licensing and Background Checks (Health Facility Licensing) — (801) 890-2007 (facility-based incidents)
- ☐ Long-Term Care Ombudsman — (801) 538-3910 (facility resident-rights issues)
- ☐ Adult Guardianship court / Probate Division of Utah District Court (if guardian conduct implicated)
- ☐ Bank / financial institution security or fraud unit (financial exploitation)
- ☐ Federal agency (Medicare fraud, SSA representative-payee misuse, IRS, FBI)
- ☐ Treating physician / facility risk management
- ☐ Family / health-care agent / POA
10. STATUTORY AUTHORITY AND MANDATORY-REPORTING COMPLIANCE
10.1. Mandatory reporting. Utah Code § 26B-6-205 requires that "any person who has reason to believe that a vulnerable adult is being abused, neglected, or exploited, or has been abused, neglected, or exploited, shall immediately notify Adult Protective Services intake or the nearest peace officer."
10.2. No clergy-penitent or attorney-client exception except as expressly preserved. The mandatory-reporting duty applies to professionals subject only to the narrow privileges expressly preserved in § 26B-6-205. Verify privilege analysis with counsel before withholding any report.
10.3. Contents required. A report must include, to the extent known: (a) the name, address, age, and condition of the vulnerable adult; (b) the name, address, and relationship of the alleged perpetrator; (c) the nature and extent of the abuse, neglect, or exploitation; and (d) any other information the reporter believes is relevant.
10.4. Penalty for failure to report. Failure to make a required report is a class B misdemeanor under Utah Code § 26B-6-209. Knowingly making a false report may also be subject to criminal penalties.
10.5. Coordinated investigation. APS must investigate within statutory timelines (generally three (3) business days for non-emergent reports and immediately for emergencies); APS coordinates with law enforcement under § 26B-6-207.
11. REPORTER AFFIRMATION, IMMUNITY, AND CONFIDENTIALITY
11.1. Good-faith immunity. Utah Code § 26B-6-206 provides that any person who in good faith makes a report, takes photographs, or participates in an investigation or judicial proceeding regarding alleged abuse, neglect, or exploitation of a vulnerable adult is immune from any civil or criminal liability that might otherwise arise from the report or participation, except where the person is the alleged perpetrator.
11.2. Confidentiality. Reports, records, and identifying information are confidential under Utah Code § 26B-6-210 and are released only as expressly authorized by statute or by court order.
11.3. Anti-retaliation. Employers may not retaliate against an employee who in good faith makes a report; the reporter may pursue civil remedies for retaliation in addition to those provided under federal whistleblower statutes.
12. SIGNATURE, VERIFICATION, AND CERTIFICATE OF TRANSMISSION
I, [REPORTER FULL NAME], declare under penalty of perjury under the laws of the State of Utah that I have personally observed or have reason to believe the matters described above; that the information set forth is true and correct to the best of my knowledge, information, and belief; and that this report is made in good faith pursuant to Utah Code § 26B-6-205.
Date: [__/__/____]
[________________________________]
[REPORTER NAME]
Certificate of Transmission. I hereby certify that on [__/__/____] at [__:__] I transmitted the foregoing report to Utah Adult Protective Services by:
- ☐ Telephone to 1-800-371-7897 — confirmation #: [___]
- ☐ Online intake at https://daas.utah.gov/adult-protective-services — confirmation #: [___]
- ☐ U.S. Mail to DAAS — APS, 195 North 1950 West, Salt Lake City, UT 84116
- ☐ In-person delivery to local APS office at [___]
- ☐ Fax to [___-___-____]
[________________________________]
[REPORTER / TRANSMITTER NAME]
13. UTAH PRACTICE NOTES
- Title 62A → Title 26B recodification. Utah's S.B. 84 (2022 General Session) consolidated former Title 62A (Human Services) into Title 26B effective in stages. The Adult Protective Services Act (formerly § 62A-3-301 et seq.) is now codified at § 26B-6-201 et seq. Some practitioners and forms still cite the older sections; verify current numbering on le.utah.gov before filing.
- APS administrative home. APS is housed in the DHHS Division of Aging and Adult Services (DAAS), not the former Division of Aging and Adult Services within Title 62A. The hotline (1-800-371-7897), online intake, and statewide intake address remain consistent with the predecessor program.
- Facility-based incidents. Reports involving abuse or neglect within a licensed nursing facility, assisted living facility, intermediate care facility, or hospice program should be made to APS AND to the DHHS Division of Licensing and Background Checks at (801) 890-2007. The Long-Term Care Ombudsman (801-538-3910) is an additional advocacy resource for resident-rights complaints.
- Financial exploitation. Utah enacted vulnerable-adult financial-exploitation provisions specific to financial institutions (see Utah Code Title 7 and § 26B-6 area provisions authorizing transaction holds and reporting to APS). Banks may delay transactions on suspected exploitation and report without civil liability.
- Capacity vs. consent. A vulnerable adult with capacity may decline protective services. APS must respect that refusal absent a finding of imminent danger or caretaker interference. If capacity is in doubt, consider whether a guardianship petition is needed under Utah Code § 75-5-301 et seq.
- Concurrent criminal referral. Conduct meeting Utah Code § 76-5-111 (abuse, neglect, or exploitation of a vulnerable adult) thresholds should be referred to law enforcement immediately. APS coordinates but does not displace criminal investigation.
- Anonymous reporting. Anonymous reports are accepted, but providing reporter contact information enables APS to follow up, request additional facts, and document the chain of evidence.
14. SOURCES AND REFERENCES
- Utah Code Title 26B Chapter 6 Part 2 (Vulnerable Adult Protection) — https://le.utah.gov/xcode/Title26B/Chapter6/26B-6-P2.html
- Utah Code § 26B-6-205 (mandatory reporting) — https://le.utah.gov/xcode/Title26B/Chapter6/26B-6-S205.html
- Utah Code § 26B-6-206 (immunity) — https://le.utah.gov/xcode/Title26B/Chapter6/26B-6-S206.html
- Utah Code § 76-5-111 et seq. (criminal abuse of vulnerable adult) — https://le.utah.gov/xcode/Title76/Chapter5/76-5-P1.html
- Utah Admin. Code R510-302 (APS) — https://rules.utah.gov/publicat/code/r510/r510-302.htm
- Utah DHHS Division of Aging and Adult Services / APS — https://daas.utah.gov/adult-protective-services/
- DAAS APS reporting page — https://daas.utah.gov/adult-protective-services/
- DHHS Division of Licensing and Background Checks (facility complaints) — https://dlbc.utah.gov/submit-a-concern/
- Utah DHHS main site — https://dhhs.utah.gov
- 2023 Utah Code recodification overview (S.B. 84) — https://le.utah.gov
Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. An attorney licensed in Utah should review and customize this document. Hotline numbers, addresses, and statutory citations are subject to change; verify all authorities against current Utah DHHS publications before use.
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
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