Virginia Adult Protective Services (APS) Report — Abuse, Neglect, or Exploitation of an Adult

VIRGINIA ADULT PROTECTIVE SERVICES (APS) REPORT — ABUSE, NEGLECT, OR EXPLOITATION OF AN ADULT

EMERGENCY: If you believe an adult is in immediate physical danger, dial 911 first, then call the Virginia APS Hotline.

VIRGINIA APS HOTLINE (24 hours, toll-free): 1-888-832-3858

ONLINE REPORTING PORTAL: https://www.dars.virginia.gov/aps/APSreport.htm

LOCAL DSS: Report may also be made to the city/county Department of Social Services where the adult resides.

TABLE OF CONTENTS

1. Reporter Information
2. Mandated Reporter Status and Statutory Basis
3. Adult-Subject Information
4. Alleged Conduct — Abuse, Neglect, or Exploitation
5. Specific Allegations and Narrative
6. Alleged Perpetrator(s)
7. Witnesses and Collateral Contacts
8. Evidence and Attachments
9. Immediate Risk and Safety Assessment
10. Prior Reports, Court Orders, and Related Proceedings
11. Confidentiality and Immunity
12. Reporter Certification and Signature
13. Internal Tracking (Mandated Reporter Organizations)
14. Virginia Practice Notes
15. Sources and References

1. REPORTER INFORMATION

Date of Report: [__/__/____]

Time of Phone/Online Report: [__:__ AM/PM]

APS Intake Reference / Case Number (if assigned): [________________________________]

Reporter requests: ☐ Confidential reporter status (per Va. Code § 63.2-1608) ☐ Updates regarding APS disposition to the extent permitted by law

2. MANDATED REPORTER STATUS AND STATUTORY BASIS

Reporter ☐ is ☐ is not a mandated reporter under Va. Code § 63.2-1606(A). If mandated, identify category (☐ check all that apply):

• ☐ Licensed/certified/registered health professional (physician, nurse, dentist, pharmacist, chiropractor, etc.) — except veterinarians
• ☐ Mental-health services provider as defined in Va. Code § 54.1-2400.1
• ☐ Emergency medical services provider
• ☐ Guardian or conservator of an adult
• ☐ Person employed by or contracting with a public or private agency or facility, including assisted living, nursing facility, hospital, adult day-care, or home-care provider, whether in administrative, supportive, or direct care capacity
• ☐ Paid caregiver, including a personal-care attendant, companion, sitter, or homemaker
• ☐ Law-enforcement officer
• ☐ Behavior-analysis practitioner

Reporter acknowledges that, as a mandated reporter, the report must be made immediately upon forming a reasonable suspicion that an adult is being abused, neglected, or exploited (Va. Code § 63.2-1606(A)).

3. ADULT-SUBJECT INFORMATION

4. ALLEGED CONDUCT — ABUSE, NEGLECT, OR EXPLOITATION

Check all that apply. Definitions per Va. Code § 63.2-1603 and 22 VAC 30-100-10.

Abuse:

• ☐ Physical abuse (hitting, slapping, pushing, restraint injuries, unexplained bruising)
• ☐ Sexual abuse / sexual assault (Va. Code § 18.2-67.1 et seq.)
• ☐ Mental/emotional/psychological abuse (threats, intimidation, isolation, verbal humiliation)
• ☐ Use of physical or chemical restraints not authorized by physician order
• ☐ Failure to provide goods or services necessary to avoid physical harm or mental anguish

Neglect (including self-neglect):

• ☐ Caregiver neglect (failure of a caregiver to provide food, clothing, shelter, medical care, supervision)
• ☐ Self-neglect (adult unable to provide for own needs and lacks capacity to consent to services)
• ☐ Medication mismanagement / failure to administer prescribed medications
• ☐ Hygiene neglect / pressure injuries / dehydration / malnutrition
• ☐ Failure to provide a safe environment

Exploitation (financial or other):

• ☐ Misuse of funds, property, or assets by an agent, family member, caregiver, or third party
• ☐ Coerced or fraudulent transfers (deeds, account additions, beneficiary changes)
• ☐ Theft, forgery, or unauthorized debit/credit/ATM transactions
• ☐ Romance, lottery, IRS/Social Security, or technical-support scams
• ☐ Undue influence regarding wills, trusts, powers of attorney
• ☐ Wage/benefit theft (SSA, VA, pension diversion)
• ☐ Misuse of representative-payee or fiduciary authority

5. SPECIFIC ALLEGATIONS AND NARRATIVE

5.1. Date and time of alleged incident(s). [________________________________]

5.2. Location of alleged incident(s). [________________________________]

5.3. Detailed narrative. Describe what was observed or learned, by whom, and when. Use the adult's own words where possible (in quotation marks). Avoid characterization; describe observable facts.

[NARRATIVE — minimum facts to capture: who, what, when, where, how, and how the reporter knows. Include the adult's verbatim statements, the demeanor and physical condition observed, environmental conditions (cleanliness, food, heat/cooling, hazards), description of injuries with location and color/age of bruising, financial irregularities (account names, dates, amounts, payees), and statements made by the alleged perpetrator. Be specific and chronological.]

5.4. Pattern. Is the conduct ☐ a single incident ☐ ongoing/repetitive ☐ escalating in frequency or severity?

5.5. Adult's awareness and capacity. Does the adult ☐ acknowledge the conduct ☐ deny it ☐ appear unaware ☐ appear afraid to disclose? Reporter's observation regarding the adult's ability to make informed decisions: [________________________________].

6. ALLEGED PERPETRATOR(S)

For each alleged perpetrator (add additional rows as needed):

7. WITNESSES AND COLLATERAL CONTACTS

8. EVIDENCE AND ATTACHMENTS

Attached / available upon request (☐ check all that apply):

• ☐ Photographs (of injuries, living conditions, documents) — Tab [____]
• ☐ Medical records / hospital discharge summary — Tab [____]
• ☐ Bank/brokerage statements showing irregular transactions — Tab [____]
• ☐ Cancelled checks, money orders, wire-transfer receipts — Tab [____]
• ☐ Power of Attorney, will, trust, deed, beneficiary forms — Tab [____]
• ☐ Text messages, emails, voicemails — Tab [____]
• ☐ Surveillance / doorbell-camera footage — Tab [____]
• ☐ Police reports / 911 call logs — Tab [____]
• ☐ Facility incident reports / nursing notes — Tab [____]
• ☐ Care plan, medication administration record (MAR) — Tab [____]
• ☐ Other: [________________________________]

8.1. Photograph/Recording Consent. Per Va. Code § 63.2-1606, photographs or video recordings of the adult may be taken with the informed consent of the adult or the adult's legal representative; do not photograph the adult without consent unless authorized by law.

9. IMMEDIATE RISK AND SAFETY ASSESSMENT

9.1. Is the adult in immediate physical danger? ☐ Yes ☐ No. If yes, has 911 been called? ☐ Yes ☐ No (Time: [__:__ AM/PM]).

9.2. Does the adult require emergency medical attention? ☐ Yes ☐ No.

9.3. Is the alleged perpetrator currently with or with access to the adult? ☐ Yes ☐ No.

9.4. Are there other vulnerable adults or children in the home/facility who may also be at risk? ☐ Yes ☐ No — Identify: [________].

9.5. Recommended interim protective measures (for APS consideration; ultimate authority lies with APS, law enforcement, and the courts):

• ☐ Welfare check by law enforcement
• ☐ Emergency Protective Services Order (Va. Code § 63.2-1610) for an incapacitated adult lacking capacity to consent
• ☐ Emergency guardianship/conservatorship petition (Va. Code § 64.2-2014)
• ☐ Protective Order (Va. Code § 19.2-152.10 / § 16.1-279.1) — family abuse or stalking
• ☐ Adult Abuse, Neglect, and Exploitation criminal referral (Va. Code §§ 18.2-369, 18.2-178.2)
• ☐ Removal of agent under Durable POA / suspension of fiduciary authority
• ☐ Hold or freeze on financial accounts pursuant to Va. Code § 63.2-1606(K)/(L) (financial-institution provisions — verify subsection letter)
• ☐ Adult day services / in-home services referral
• ☐ Other: [________________________________]

10. PRIOR REPORTS, COURT ORDERS, AND RELATED PROCEEDINGS

10.1. Prior APS reports. ☐ Yes ☐ No ☐ Unknown — Describe: [________________________________].

10.2. Active court orders. ☐ Guardianship ☐ Conservatorship ☐ Protective order ☐ Civil commitment ☐ None ☐ Unknown.

10.3. Open law-enforcement investigation. ☐ Yes (Agency: [________], Detective: [________], Case #: [________]) ☐ No ☐ Unknown.

10.4. Open civil litigation (e.g., contested guardianship, will contest, undue-influence claim): [________________________________].

11. CONFIDENTIALITY AND IMMUNITY

11.1. Confidentiality. APS records, including the identity of the reporter, are confidential under Va. Code § 63.2-1608 and 22 VAC 30-100-30, subject to limited exceptions (court order, multi-disciplinary teams, prosecutorial use, federal data exchange, named subject of a substantiated finding upon administrative review).

11.2. Immunity. A person who makes a report or provides records or information under Va. Code § 63.2-1606, or who testifies in any judicial proceeding arising therefrom, is immune from civil or criminal liability for the report or testimony, unless the person acted in bad faith or with malicious purpose. (Verify current subsection letter — historically subsection D, currently codified at § 63.2-1606.)

11.3. Anti-Retaliation. An employer may not prohibit a mandated reporter from reporting directly to the local department or to the APS hotline (Va. Code § 63.2-1606(F)). Retaliation against a good-faith reporter may give rise to claims under Va. Code § 40.1-27.3 (Bowman / public-policy retaliation) and other statutory protections.

11.4. Penalties for Failure to Report. A mandated reporter who knowingly fails to report is subject to civil penalty: up to $500 for the first violation and $100 to $1,000 for subsequent violations (Va. Code § 63.2-1606).

12. REPORTER CERTIFICATION AND SIGNATURE

I certify under penalty of perjury under the laws of the Commonwealth of Virginia that the information contained in this report is true and correct to the best of my knowledge, that I have a reasonable basis to suspect that the adult identified above is being abused, neglected, or exploited, and that I am making this report in good faith pursuant to Va. Code § 63.2-1606.

Date: [__/__/____]

Time: [__:__ AM/PM]

[________________________________]

[REPORTER NAME]

[REPORTER TITLE / ORGANIZATION]

13. INTERNAL TRACKING (MANDATED REPORTER ORGANIZATIONS)

For organizational compliance documentation (HR / Compliance / Legal). Not transmitted to APS unless requested.

14. VIRGINIA PRACTICE NOTES

• Adult Defined. Under Va. Code § 63.2-1603, APS jurisdiction extends to (a) any adult age 60 or older, and (b) any incapacitated adult age 18 or older. "Incapacitated" generally means the adult is impaired by reason of mental illness, intellectual or developmental disability, physical illness, or other cause to the extent the adult lacks sufficient understanding or capacity to make, communicate, or carry out responsible decisions.
• Self-Neglect. Virginia recognizes self-neglect as a basis for APS intervention. Where a competent adult declines services, APS generally must respect the adult's decision absent emergency circumstances or a finding of incapacity.
• Immediate Reporting. Mandated reporters must report immediately — Virginia does not provide a 24- or 72-hour grace period. Document the time of suspicion formation and the time of report.
• Hotline vs. LDSS. Calls to the 24-hour hotline are routed to the appropriate local department of social services. Reporters may also call the LDSS directly during business hours.
• Investigation Timeline. APS must respond within statutory and regulatory timeframes (typically 24 hours for emergencies, 5 business days for routine reports), under 22 VAC 30-100.
• Facility-Based Allegations. Allegations involving licensed facilities (assisted living, nursing facilities, adult day care, home care) trigger parallel investigations by the licensing agency (VDH Office of Licensure and Certification for nursing facilities; VDSS Division of Licensing Programs for assisted living and adult day care).
• Financial Exploitation — Bank Holds. Va. Code § 63.2-1606 authorizes financial institutions to refuse, delay, or hold transactions where exploitation is suspected, with statutory immunity. Coordinate with the financial institution's elder-protection officer.
• Criminal Cross-Referral. APS does not prosecute. Coordinate with the Commonwealth's Attorney and local law enforcement for criminal charges under Va. Code §§ 18.2-369 (abuse/neglect of incapacitated adult) and 18.2-178.2 (financial exploitation of vulnerable adult).
• Guardianship / Conservatorship. If protection requires court intervention, consider an emergency petition under Va. Code § 64.2-2014 (J&DR or Circuit Court).

15. SOURCES AND REFERENCES

• Virginia Department for Aging and Rehabilitative Services (DARS) — Adult Protective Services Division — https://www.dars.virginia.gov/aps/
• DARS APS Reporting Portal — https://www.dars.virginia.gov/aps/APSreport.htm
• Virginia APS Hotline — 1-888-832-3858 (24 hours)
• Virginia Department of Social Services — Adult Protective Services — https://www.dss.virginia.gov/abuse/aps.cgi
• Va. Code § 63.2-1603 (Definitions) — https://law.lis.virginia.gov/vacode/title63.2/chapter16/section63.2-1603/
• Va. Code § 63.2-1605 (LDSS APS authority) — https://law.lis.virginia.gov/vacode/title63.2/chapter16/section63.2-1605/
• Va. Code § 63.2-1606 (Mandated and voluntary reporting; immunity; penalties) — https://law.lis.virginia.gov/vacode/title63.2/chapter16/section63.2-1606/
• Va. Code § 63.2-1608 (Confidentiality) — https://law.lis.virginia.gov/vacode/title63.2/chapter16/section63.2-1608/
• Va. Code § 63.2-1610 (Emergency Protective Services Order) — https://law.lis.virginia.gov/vacode/title63.2/chapter16/section63.2-1610/
• Va. Code § 18.2-369 (Abuse and neglect of incapacitated adults) — https://law.lis.virginia.gov/vacode/title18.2/chapter9/section18.2-369/
• Va. Code § 18.2-178.2 (Financial exploitation of vulnerable adults) — https://law.lis.virginia.gov/vacode/title18.2/chapter6/section18.2-178.2/
• 22 VAC 30-100 (APS regulations) — https://law.lis.virginia.gov/admincode/title22/agency30/chapter100/
• Long-Term Care Ombudsman Program (Virginia) — https://www.elderrights.virginia.gov/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Calling the Virginia APS Hotline (1-888-832-3858) or filing online through the DARS portal is the operative report; this packet documents the report for the reporter's records and any later proceeding. An attorney licensed in Virginia should review fact-specific applications, especially those involving facility-based allegations, financial exploitation, or guardianship-related abuse.