Wisconsin Adult Protective Services Report (Elder/Adult-at-Risk)

WISCONSIN ADULT PROTECTIVE SERVICES REPORT — ELDER ADULT AT RISK / ADULT AT RISK

TABLE OF CONTENTS

1. Receiving Agency and Filing Information
2. Reporter Information and Mandatory-Reporter Status
3. Subject Adult Information
4. Alleged Perpetrator Information
5. Nature of Allegation
6. Description of Incident(s)
7. Evidence and Corroboration
8. Risk Assessment and Imminent-Harm Indicators
9. Capacity and Consent Considerations
10. Statutory Basis for Report
11. Requested Action
12. Reporter Certification and Immunity Acknowledgment
13. Wisconsin Practice Notes
14. Sources and References

1. RECEIVING AGENCY AND FILING INFORMATION

2. REPORTER INFORMATION AND MANDATORY-REPORTER STATUS

2.1. Reporter name: [________________________________]

2.2. Reporter title / occupation: [________________________________]

2.3. Reporter employer / agency: [________________________________]

2.4. Reporter business address: [________________________________]

2.5. Reporter telephone: [________]

2.6. Reporter email: [________________________________]

2.7. Mandatory-reporter status under Wis. Stat. § 46.90(4)(ab) — check all that apply:

• ☐ Employee of an entity licensed, certified, or approved by or registered with DHS;
• ☐ Health care provider (physician, physician assistant, nurse, psychologist);
• ☐ Social worker certified under Wis. Stat. ch. 457;
• ☐ Professional counselor certified under Wis. Stat. ch. 457;
• ☐ Marriage and family therapist certified under Wis. Stat. ch. 457;
• ☐ Person providing care or services to an elder adult at risk under contract;
• ☐ Person who, for compensation or other benefit, manages the financial affairs of an elder adult at risk;
• ☐ Reporter is NOT a mandatory reporter but is making a permissive good-faith report.

2.8. Relationship to subject adult: [________________________________]

3. SUBJECT ADULT INFORMATION

3.1. Subject's full legal name: [________________________________]

3.2. Date of birth: [__/__/____] 3.3. Age: [____]

3.4. Sex / gender: [________]

3.5. Residence address: [________________________________]

3.6. Residential setting:

• ☐ Private home;
• ☐ Apartment;
• ☐ Adult family home;
• ☐ Community-based residential facility (CBRF);
• ☐ Residential care apartment complex (RCAC);
• ☐ Nursing home (Wis. Admin. Code DHS 132);
• ☐ Hospital;
• ☐ Other: [________________________________].

3.7. Subject classification:

• ☐ Elder adult at risk under Wis. Stat. § 46.90(1)(br) — person aged 60+ exposed to abuse, neglect, self-neglect, or financial exploitation;
• ☐ Adult at risk under Wis. Stat. § 55.01(1e) — adult who has a physical or mental condition that substantially impairs their ability to care for their needs and who has experienced, is currently experiencing, or is at risk of experiencing abuse, neglect, self-neglect, or financial exploitation.

3.8. Known physical, cognitive, or mental conditions: [________________________________]

3.9. Primary language / communication needs: [________________________________]

3.10. Current legal representatives (if known):

4. ALLEGED PERPETRATOR INFORMATION

4.1. Name: [________________________________]

4.2. Relationship to subject: [________________________________]

4.3. Address: [________________________________]

4.4. Telephone: [________]

4.5. Has the alleged perpetrator had access to the subject within the last 30 days? ☐ Yes ☐ No

4.6. Does the alleged perpetrator currently reside with the subject? ☐ Yes ☐ No

4.7. Is the alleged perpetrator employed at the subject's residence (e.g., in-home caregiver, agency staff, facility employee)? ☐ Yes ☐ No — if Yes, employer: [________________________________]

4.8. Known criminal or APS history (if any): [________________________________]

5. NATURE OF ALLEGATION

• ☐ Physical abuse — intentional or reckless infliction of physical pain or injury;
• ☐ Emotional abuse — language or behavior that serves no legitimate purpose and intends to be intimidating, humiliating, threatening, frightening, or harassing;
• ☐ Sexual abuse — sexual contact or intercourse without consent or with a person incapable of consent;
• ☐ Neglect by another — failure of a caregiver, despite an assumed responsibility, to provide essential food, shelter, medical care, supervision, or services;
• ☐ Self-neglect — significant danger to the adult's own health or safety due to inability or refusal to obtain essential needs;
• ☐ Financial exploitation — obtaining, retaining, or using the property of an adult at risk without consent or by deception, intimidation, or undue influence (includes theft, forgery, abuse of POA, fraudulent transfers, telemarketing/lottery scams, and undue influence over estate planning);
• ☐ Treatment without consent — administration of medication or performance of psychosurgery, electroconvulsive therapy, or experimental research without informed consent and lawful authority;
• ☐ Unreasonable confinement or restraint — restraint of a competent adult against the adult's will, or restraint inconsistent with applicable care plans.

6. DESCRIPTION OF INCIDENT(S)

6.1. Date(s) of incident(s): [__/__/____] to [__/__/____]

6.2. Location(s) of incident(s): [________________________________]

6.3. Detailed narrative (use additional pages as needed):

[____________________________________________________________]

[____________________________________________________________]

[____________________________________________________________]

6.4. Frequency / pattern (one-time, ongoing, escalating, cyclic): [________________________________]

6.5. Source of reporter's knowledge:

• ☐ Direct observation;
• ☐ Statement by subject;
• ☐ Statement by witness — name: [________];
• ☐ Documentary evidence;
• ☐ Disclosure during professional encounter;
• ☐ Other: [________________________________].

7. EVIDENCE AND CORROBORATION

7.1. Physical evidence observed (bruising, weight loss, pressure ulcers, hygiene, environmental hazards, missing property, account irregularities): [________________________________]

7.2. Documentary evidence available:

• ☐ Photographs;
• ☐ Medical records / treatment notes;
• ☐ Bank or brokerage statements;
• ☐ Power of attorney instruments;
• ☐ Recently executed wills, trusts, or deed transfers;
• ☐ Cash withdrawals or wire transfers;
• ☐ Email, text, or social media messages;
• ☐ Care-plan documentation;
• ☐ Facility incident reports.

7.3. Witnesses:

8. RISK ASSESSMENT AND IMMINENT-HARM INDICATORS

8.1. Indicators of imminent danger — check all that apply:

• ☐ Recent or current physical injury;
• ☐ Threats of harm by alleged perpetrator;
• ☐ Access of alleged perpetrator to weapons, medication, or financial accounts;
• ☐ Withholding of food, water, medication, or essential care;
• ☐ Subject expresses fear or distress;
• ☐ Subject lacks capacity to protect self;
• ☐ Unattended medical condition;
• ☐ Substantial financial loss imminent (pending transfer, account drain);
• ☐ Isolation from family, friends, or services;
• ☐ Caregiver impairment (substance use, untreated mental illness).

8.2. Has 911 / law enforcement been contacted for emergency response? ☐ Yes ☐ No — if yes, agency and case #: [________________________________]

8.3. Has the subject been transported for emergency medical evaluation? ☐ Yes ☐ No — if yes, facility: [________________________________]

9. CAPACITY AND CONSENT CONSIDERATIONS

9.1. Does the subject appear to have decisional capacity? ☐ Yes ☐ No ☐ Unclear / fluctuating

9.2. Has the subject consented to a report being made? ☐ Yes ☐ No ☐ Not applicable / unable to consent

9.3. Is the subject under guardianship under Wis. Stat. ch. 54 or protective placement / services under ch. 55? ☐ Yes ☐ No

9.4. ☐ Reporter believes circumstances may warrant emergency protective services or emergency protective placement under Wis. Stat. § 55.135.

9.5. ☐ Reporter believes circumstances may warrant a domestic-abuse, harassment, or elder-adult-at-risk restraining order under Wis. Stat. § 813.123.

10. STATUTORY BASIS FOR REPORT

10.1. ☐ § 46.90(4)(a)1. — The elder adult at risk has requested that the reporter make this report.

10.2. ☐ § 46.90(4)(a)2. — The reporter has reasonable cause to believe that the elder adult at risk is at imminent risk of serious bodily harm, death, sexual assault, or significant property loss and is unable to make an informed judgment about whether to report the risk.

10.3. ☐ § 55.043 — Report concerning an adult at risk under age 60 alleging abuse, financial exploitation, neglect, or self-neglect.

10.4. ☐ Wis. Admin. Code DHS 13 — Report of caregiver misconduct involving an entity-regulated caregiver.

10.5. ☐ Permissive good-faith report by a non-mandated reporter.

11. REQUESTED ACTION

11.1. Reporter requests that the receiving agency:

• ☐ Initiate an investigation under § 55.043 within twenty-four (24) hours, excluding Saturdays, Sundays, and legal holidays;
• ☐ Coordinate with law enforcement under § 55.043(1r)(b);
• ☐ Refer to the Wisconsin Department of Justice or county district attorney for criminal review under § 940.285 or § 940.295;
• ☐ Refer to DHS Division of Quality Assurance (DQA) for facility-level review;
• ☐ Refer to the Board on Aging and Long-Term Care Ombudsman where the subject resides in a long-term care facility;
• ☐ Refer for emergency protective services / placement under § 55.135;
• ☐ Refer to the Wisconsin Office of the Commissioner of Insurance and/or financial institution for asset freeze where financial exploitation is alleged;
• ☐ Provide written disposition of the report to the reporter to the extent permitted by law.

11.2. Reporter is available for follow-up at: [________________________________]

12. REPORTER CERTIFICATION AND IMMUNITY ACKNOWLEDGMENT

12.1. I certify that the foregoing information is true and correct to the best of my knowledge and is reported in good faith.

12.2. I understand that, pursuant to Wis. Stat. § 46.90(4)(b) and § 55.043(1m)(c), a person who reports under these sections in good faith is immune from civil and criminal liability arising from the report.

12.3. I understand that, under Wis. Stat. § 46.90(4)(c), an employer may not discharge, retaliate against, or discriminate against an employee for making a good-faith report; an adverse action taken within one hundred twenty (120) days of a good-faith report creates a rebuttable presumption that the action was retaliatory.

12.4. I understand that the identity of the reporter is confidential and may only be released as authorized by § 46.90(5)(b) or court order.

Reporter signature: [________________________________]

Date: [__/__/____]

Time: [____ : ____]

13. WISCONSIN PRACTICE NOTES

• Statewide Wisconsin Elder Abuse Hotline. 1-833-586-0107. Reports about an elder adult at risk (age 60+) may be routed through the statewide hotline; reports are forwarded to the county of responsibility for response. Reports for adults at risk under age 60 should be directed to the county adult-at-risk agency listed at https://www.dhs.wisconsin.gov/aps/aar-agencies.htm.
• County designation. Each county board designates an elder-adult-at-risk agency under § 46.90(2) and an adult-at-risk agency under § 55.043(1d). In Milwaukee County, DHS itself functions as the agency for portions of the population.
• 24-hour response. Investigations not referred to DHS must commence within twenty-four (24) hours of report, excluding Saturdays, Sundays, and legal holidays, per § 55.043(1m)(b).
• No statutory time limit on reporting. There is no statute of limitations specifically for filing an APS report, but mandatory reporters should report immediately upon forming reasonable cause; criminal statutes of limitations apply to underlying offenses (see § 939.74).
• Duty to know. A health care professional or social worker who fails to report when required may be subject to professional discipline by the relevant DSPS licensing board, even though the statute itself imposes no general criminal penalty for failure to report.
• Concurrent reporting obligations. Reports involving long-term care facility employees may also trigger DHS Division of Quality Assurance complaint procedures and Caregiver Misconduct Reporting under Wis. Admin. Code DHS 13. Reports involving licensed health professionals may also require referral to the Department of Safety and Professional Services.
• Confidentiality. APS records are confidential under § 46.90(5) and § 55.043(7). Reporter identity is protected from disclosure absent court order or written waiver.
• Reporter immunity. Good-faith reports are immune from civil and criminal liability. Retaliation against an employee-reporter creates a rebuttable presumption when adverse action occurs within 120 days.
• Emergency intervention. If the adult faces imminent harm, call 911. Emergency protective placement under § 55.135 is available where the standards of § 55.135(1) are met. A petition for protective services or placement may follow under § 55.075.
• Restraining orders. A petition under § 813.123 may be brought by or on behalf of an elder adult at risk to enjoin contact, harassment, or financial exploitation.

14. SOURCES AND REFERENCES

• Wisconsin Department of Health Services — Adult Protective Services — https://www.dhs.wisconsin.gov/aps/index.htm
• Wisconsin Elder Abuse Hotline — https://gwaar.org/elder-abuse-hotline (1-833-586-0107)
• Adults at Risk Agencies by Wisconsin County — https://www.dhs.wisconsin.gov/aps/aar-agencies.htm
• Elder-Adult-at-Risk Agencies by Wisconsin County — https://www.dhs.wisconsin.gov/aps/ear-agencies.htm
• Adult-at-Risk, Including Elder Adult-at-Risk, Reporting (DHS Pub. P-01214) — https://www.dhs.wisconsin.gov/publications/p01214.pdf
• Wis. Stat. § 46.90 — https://docs.legis.wisconsin.gov/statutes/statutes/46/90
• Wis. Stat. § 55.043 — https://docs.legis.wisconsin.gov/statutes/statutes/55/043
• Wis. Stat. ch. 55 (Protective Services System) — https://docs.legis.wisconsin.gov/statutes/statutes/55
• Wis. Stat. § 813.123 (Elder Adult at Risk Restraining Orders) — https://docs.legis.wisconsin.gov/statutes/statutes/813/123
• Wis. Stat. § 940.285 (Abuse of vulnerable adults) — https://docs.legis.wisconsin.gov/statutes/statutes/940/iii/285
• Wisconsin Board on Aging and Long-Term Care — https://longtermcare.wi.gov
• Wis. Admin. Code DHS 13 (Caregiver Misconduct Reporting) — https://docs.legis.wisconsin.gov/code/admin_code/dhs/001/13

Disclaimer: This template is provided for informational purposes only and does not constitute legal advice. Mandatory reporters should consult their licensing board and qualified legal counsel for application of these statutes to specific facts. Verify the current statewide hotline number, county agency contacts, and statutory citations before submission.