Vermont Adult Protective Services Report (Vulnerable Adult Abuse, Neglect, Exploitation)

VERMONT ADULT PROTECTIVE SERVICES REPORT — VULNERABLE ADULT

TABLE OF CONTENTS

1. Reporter Information
2. Mandatory-Reporter Status and Trigger
3. Vulnerable Adult Information
4. Alleged Perpetrator(s) / Caregiver(s)
5. Nature of the Allegation
6. Detailed Narrative
7. Witnesses, Evidence, and Collateral Contacts
8. Risk and Safety Assessment
9. Prior Reports and Concurrent Reporting
10. Statutory Acknowledgments
11. Transmission to Vermont APS
12. Reporter Certification and Signature
13. Vermont Practice Notes
14. Sources and References

1. REPORTER INFORMATION

2. MANDATORY-REPORTER STATUS AND TRIGGER

2.1. Reporter is a mandatory reporter under 33 V.S.A. § 6903(a) because reporter is an employee, contractor, volunteer, or grantee who directly provides one or more of the following services to adults:

• ☐ Health care (e.g., physician, nurse, EMT, paramedic, mental-health clinician, pharmacist, therapist);
• ☐ Law enforcement;
• ☐ Caregiving (paid or contract caregiver, home health aide, personal care attendant, residential care staff, nursing facility staff);
• ☐ Counseling;
• ☐ Education;
• ☐ Social services;
• ☐ Other (describe): [________________________________].

2.2. Reporter is a voluntary reporter under 33 V.S.A. § 6903(c) (concerned person not in any mandatory category above). ☐ Yes ☐ No.

2.3. Reporting Trigger. Reporter:

• ☐ Has actual knowledge of abuse, neglect, or exploitation of a vulnerable adult;
• ☐ Has reasonable cause to suspect abuse, neglect, or exploitation of a vulnerable adult;
• ☐ Was a direct witness to evidence of abuse, neglect, or exploitation;
• ☐ Received a complaint of abuse, neglect, or exploitation.

2.4. Privilege. Reporter may not refuse to report on grounds of privilege or confidentiality (33 V.S.A. § 6903(b)), except for the narrow exemptions for crisis workers and the State Long-Term Care Ombudsman with respect to confidential communications.

2.5. Multi-Reporter Filing. ☐ This report is filed on behalf of multiple mandatory reporters who jointly witnessed the same conduct. Co-reporters: [________________________________].

3. VULNERABLE ADULT INFORMATION

3.1. Definition (33 V.S.A. § 6902). A "vulnerable adult" is a person 18 years of age or older who: (A) is a resident of a facility required to be licensed under 33 V.S.A. Chapter 71; (B) is a resident of a psychiatric hospital, intermediate care facility, or nursing home; (C) has been receiving personal care or services in their place of residence; or (D) regardless of residence or services received, has an impairment or disability that limits the person's ability to provide for their own care or protection because of physical, mental, or developmental disability, age-related decline, or other condition.

3.2. Identification.

3.3. Basis for "Vulnerable Adult" Status. The adult qualifies as a vulnerable adult under 33 V.S.A. § 6902 because:

• ☐ Resident of a licensed facility (NF, RCH, ALR, ICF/IID);
• ☐ Resident of a psychiatric hospital;
• ☐ Receiving personal care or services in own home (e.g., HCBS, Choices for Care, agency-with-choice);
• ☐ Has a physical, intellectual, or developmental disability impairing self-care;
• ☐ Has a cognitive impairment (dementia, Alzheimer's, TBI, stroke);
• ☐ Has a serious or persistent mental illness;
• ☐ Age-related decline limits self-protection;
• ☐ Other (describe): [________________________________].

3.4. Capacity Indicators. Based on reporter's observations: ☐ Oriented to person/place/time; ☐ Confused; ☐ Non-verbal; ☐ Has appointed guardian; ☐ Has durable power of attorney. Guardian / agent name: [________________________________].

4. ALLEGED PERPETRATOR(S) / CAREGIVER(S)

5. NATURE OF THE ALLEGATION

5.1. Reporter alleges (check all that apply):

• ☐ Abuse — Physical. Any treatment of a vulnerable adult that places the adult in fear of, or at unreasonable risk of, serious physical harm; or any unauthorized restraint or use of force. (33 V.S.A. § 6902.)
• ☐ Abuse — Emotional / Mental. Verbal threats, intimidation, isolation, harassment, or humiliation causing emotional anguish.
• ☐ Abuse — Sexual. Any non-consensual sexual contact, sexual exploitation, or any sexual contact with an adult unable to consent.
• ☐ Neglect. Failure of a caregiver to provide goods or services necessary to maintain the adult's health, safety, or welfare; OR self-neglect by an adult unable to provide for own essential needs.
• ☐ Exploitation — General. Wilful misuse of a vulnerable adult's funds, property, or other resources for the benefit of another.
• ☐ Exploitation — Financial. Theft, fraud, undue influence, abuse of POA / guardianship, identity theft, predatory lending, charitable scam, romance scam, kinship scam, or unauthorized withdrawals.
• ☐ Sexual Exploitation by Caregiver. Caregiver engages in sexual contact with vulnerable adult (per se exploitation regardless of consent).
• ☐ Other / Unknown: [________________________________].

5.2. Date(s) and Time(s) of Incident(s). [__/__/____] at [____________]; [__/__/____] at [____________].

5.3. Location of Incident(s). [________________________________].

5.4. Estimated Financial Loss (if exploitation). $[__________].

5.5. Nature of Injuries Observed. [________________________________].

6. DETAILED NARRATIVE

6.1. What was observed and when.

[________________________________]

[________________________________]

[________________________________]

6.2. Statements made by the vulnerable adult (quoted verbatim where feasible).

[________________________________]

[________________________________]

6.3. Statements made by the alleged perpetrator.

[________________________________]

[________________________________]

6.4. Statements made by other staff, family, or witnesses.

[________________________________]

[________________________________]

6.5. Pattern / history. Has reporter observed prior incidents? Describe: [________________________________].

6.6. Documentation reviewed. ☐ Medical records ☐ Bank/financial records ☐ Photos ☐ Video / surveillance ☐ Care plan / MDS ☐ Incident reports ☐ Texts / emails ☐ Other: [____________].

7. WITNESSES, EVIDENCE, AND COLLATERAL CONTACTS

Physical Evidence Available: ☐ Photographs (taken [__/__/____]) ☐ Bruise / injury photos with measuring reference ☐ Bank statements ☐ Cancelled checks ☐ Beneficiary changes ☐ Property transfers ☐ Will / trust amendments ☐ Surveillance video ☐ Voicemails ☐ Text messages ☐ Other: [____________].

Collateral Professionals:

• Primary Care Physician: [________________________________] | Tel: [____________];
• Treating Specialists: [________________________________];
• Existing Case Manager / Care Coordinator: [________________________________];
• Existing Long-Term Care Ombudsman volunteer (if facility resident): [________________________________].

8. RISK AND SAFETY ASSESSMENT

8.1. Imminent Danger? ☐ Yes — call 9-1-1 immediately and notify APS by phone at 1-800-564-1612. ☐ No.

8.2. Current Location of Vulnerable Adult. [________________________________].

8.3. Continued Access by Alleged Perpetrator. ☐ Yes ☐ No ☐ Unknown.

8.4. Vulnerable Adult's Stated Wishes (if known). [________________________________].

8.5. Decision-Making Capacity. ☐ Appears intact ☐ Diminished ☐ Lacks capacity ☐ Unknown — formal capacity evaluation pending.

8.6. Existing Protective Orders / Restraining Orders. ☐ None ☐ Family Division relief from abuse ☐ Civil Division relief from abuse of vulnerable adults (33 V.S.A. § 6933) ☐ Other: [____________].

8.7. Recommended Immediate Actions.

• ☐ Emergency medical evaluation;
• ☐ Law enforcement notification (call [____________]);
• ☐ Facility administrator / DON notification (if institutional setting);
• ☐ Long-Term Care Ombudsman referral (1-800-889-2047 ext. 3);
• ☐ Emergency guardianship petition (Probate Division);
• ☐ Petition for Relief from Abuse of Vulnerable Adults (33 V.S.A. § 6933);
• ☐ Account freeze / fraud alert;
• ☐ Other: [____________].

9. PRIOR REPORTS AND CONCURRENT REPORTING

9.1. Prior APS Reports. ☐ None known ☐ Prior report filed on [__/__/____] by [____________].

9.2. Concurrent Reports / Notifications Made by Reporter.

• ☐ Local law enforcement: [________________________________] on [__/__/____];
• ☐ Vermont State Police: [________________________________] on [__/__/____];
• ☐ State's Attorney: [________________________________] on [__/__/____];
• ☐ DLP Survey & Certification (institutional setting): [________________________________] on [__/__/____];
• ☐ Long-Term Care Ombudsman: [________________________________] on [__/__/____];
• ☐ Facility administrator: [________________________________] on [__/__/____];
• ☐ Guardian / POA: [________________________________] on [__/__/____];
• ☐ Bank fraud line / FinCEN SAR: [________________________________] on [__/__/____];
• ☐ Other: [____________].

9.3. Mandatory Reporter Notes. Reporting to APS does not satisfy independent reporting obligations to law enforcement, the facility licensing authority (DLP), or professional licensing boards.

10. STATUTORY ACKNOWLEDGMENTS

10.1. Two-Business-Day Rule. Reporter acknowledges 33 V.S.A. § 6903(a) requires reporting "within two business days" of acquiring knowledge or reason to suspect.

10.2. Failure-to-Report Penalty. 33 V.S.A. § 6913 makes failure to report a civil offense punishable by fine.

10.3. Good-Faith Immunity. Reports made in good faith are protected; the reporter's identity is held in confidence under 33 V.S.A. § 6906 except in narrowly defined circumstances.

10.4. Anti-Retaliation. Vermont law prohibits retaliation against any person who in good faith reports or participates in an APS investigation (33 V.S.A. § 6912; 13 V.S.A. Chapter 28).

10.5. Confidentiality. APS records are confidential. Reporter shall not disclose the contents of this report except as authorized by law.

10.6. No Investigation by Reporter. Reporter shall not "investigate" the allegation by interviewing the suspect, confronting the alleged perpetrator, or compromising potential evidence. The duty is to report; investigation is for APS, DLP, and law enforcement.

11. TRANSMISSION TO VERMONT APS

11.1. Primary Method — Telephone. Vermont APS Hotline: 1-800-564-1612 (Mon-Fri ~8:00 a.m.-4:30 p.m.).

11.2. After-Hours / Emergency. ☐ Call 9-1-1 if emergency. After-hours line: 1-800-649-5285.

11.3. Web Form. Vermont DAIL / Division of Licensing and Protection — APS reporting form: https://dlp.vermont.gov/aps/make-aps-report.

11.4. Mail (slowest, not preferred). Adult Protective Services Intake, HC 2 South, 280 State Drive, Waterbury, VT 05671-2020.

11.5. Confirmation. Date and time report transmitted: [__/__/____] [____________]. Method: ☐ Phone ☐ Web ☐ Mail. APS intake worker name (if obtained): [____________]. APS reference number (if assigned): [____________].

12. REPORTER CERTIFICATION AND SIGNATURE

I certify under penalty of perjury under the laws of the State of Vermont that the foregoing statements are true and correct to the best of my knowledge, information, and belief; that I am making this report in good faith; and that I have transmitted (or am about to transmit) the substance of this report to Vermont Adult Protective Services in compliance with 33 V.S.A. § 6903.

Reporter Signature: [________________________________]

Print Name: [REPORTER NAME]

Title: [TITLE]

Date: [__/__/____]

Witness (optional): [________________________________]

Print Name: [________________________________]

Date: [__/__/____]

13. VERMONT PRACTICE NOTES

• Mandatory reporter scope. Vermont's mandatory-reporter list is broader than many states and includes contractors, volunteers, and grantees of any organization "directly providing" enumerated services. Volunteers at meal-delivery programs, transportation services, and faith-based caregiver programs frequently qualify.
• Privilege override. 33 V.S.A. § 6903(b) overrides most privilege claims; only crisis workers and the State Long-Term Care Ombudsman receiving confidential communications retain a narrow exception.
• Ombudsman vs. APS. The State Long-Term Care Ombudsman Program (operated by Vermont Legal Aid under contract with DAIL) is a complaint-resolution and rights-advocacy office. APS is the investigatory body. Reports of resident-on-resident abuse, staff abuse, or neglect in licensed facilities frequently warrant simultaneous reports to APS, the Long-Term Care Ombudsman, and DLP Survey & Certification.
• Criminal coordination. Suspected criminal abuse, financial exploitation, and sexual offenses should also be reported to local law enforcement or the Vermont State Police. APS is not a criminal investigator; cases are referred to law enforcement and the State's Attorney for prosecution under 13 V.S.A. § 1375 et seq.
• Documentation discipline. Save the report copy in the reporter's professional file. If an injury is observed, photograph (with the adult's consent or with proper documentation in incident-response cases) using a measuring reference and date-stamp; do not destroy original notes.
• Self-neglect. Self-neglect IS reportable under 33 V.S.A. § 6902. APS will assess whether the adult has decisional capacity and whether protective intervention (including emergency guardianship under 14 V.S.A. § 3061 et seq.) is warranted.
• Financial exploitation special considerations. Banks and credit unions in Vermont may place a hold on suspicious transactions affecting elder customers under federal Senior Safe Act / FINRA Rule 2165 guidance; coordinate with the institution's BSA/AML officer and consider filing a SAR.
• Facility settings. If the alleged conduct occurred in a licensed facility, also submit a Survey & Certification complaint to DLP at 1-888-700-5330 to trigger an unannounced facility survey.

14. SOURCES AND REFERENCES

• Vermont Adult Protective Services — How to Report: https://dlp.vermont.gov/aps/make-aps-report
• Vermont Division of Licensing and Protection — Mandatory Reporting: https://dlp.vermont.gov/aps/mandatory-reporting
• Vermont Department of Disabilities, Aging and Independent Living: https://dail.vermont.gov/
• Vermont Statutes Online — 33 V.S.A. Chapter 69 (Reports of Abuse, Neglect, and Exploitation of Vulnerable Adults): https://legislature.vermont.gov/statutes/fullchapter/33/069
• 33 V.S.A. § 6903 (Mandatory reporters): https://legislature.vermont.gov/statutes/section/33/069/06903
• 33 V.S.A. § 6912 (Public education / non-retaliation): https://legislature.vermont.gov/statutes/section/33/069/06912
• 13 V.S.A. § 1375 et seq. (Crimes against vulnerable adults)
• Vermont Long-Term Care Ombudsman Program (Vermont Legal Aid): https://www.vtlegalaid.org/legal-projects/long-term-care-ombudsman
• DLP Survey & Certification Complaint Intake: https://dlp.vermont.gov/survey-cert/sc-complaints | 1-888-700-5330
• National Adult Protective Services Association (NAPSA): https://www.napsa-now.org/help-in-your-area/

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Mandatory reporters in Vermont must report directly to APS at 1-800-564-1612 within two (2) business days under 33 V.S.A. § 6903; this template documents the report but is NOT itself the report. In cases of imminent danger, call 9-1-1 first.