Elder Abuse Report Form

IMMEDIATE DANGER NOTICE

If the elder is in IMMEDIATE DANGER, CALL 911 FIRST.

After addressing any emergency, use this form to document the situation and report to:
- Adult Protective Services (APS)
- Long-Term Care Ombudsman (for facility residents)
- Law Enforcement

SECTION 1: REPORTER INFORMATION

1.1 Your Information

Are you a mandated reporter?
☐ Yes - Profession: _______________________________________________
☐ No

Your Name: _______________________________________________

Your Address:
_______________________________________________
_______________________________________________

Phone (Day): _______________________________________________

Phone (Evening/Mobile): _______________________________________________

Email: _______________________________________________

Relationship to the Elder:
☐ Family member: _______________________________________________
☐ Friend
☐ Neighbor
☐ Healthcare provider
☐ Social worker
☐ Facility employee
☐ Financial institution employee
☐ Other: _______________________________________________

1.2 Confidentiality

Do you want your identity kept confidential?
☐ Yes
☐ No

Note: Reporter identity is confidential in most states, but investigators may need to contact you for additional information. Anonymous reports are accepted but may be harder to investigate.

SECTION 2: ELDER (VICTIM) INFORMATION

2.1 Personal Information

Elder's Full Name: _______________________________________________

Date of Birth: _______________________________________________

Approximate Age: _______________________________________________

Gender: ☐ Male ☐ Female ☐ Other

Current Address:
_______________________________________________
_______________________________________________

Phone: _______________________________________________

2.2 Current Living Situation

Where does the elder currently live?
☐ Own home
☐ Family member's home
☐ Assisted living facility
☐ Nursing home
☐ Group home
☐ Hospital
☐ Homeless/Unknown
☐ Other: _______________________________________________

Facility Name (if applicable): _______________________________________________

Facility Address: _______________________________________________

Facility Phone: _______________________________________________

2.3 Physical/Mental Condition

Does the elder have any of the following conditions?
☐ Dementia/Alzheimer's disease
☐ Mental illness
☐ Physical disability
☐ Developmental disability
☐ Sensory impairment (vision, hearing)
☐ Limited English proficiency
☐ Other: _______________________________________________

Is the elder able to:
☐ Communicate (verbally or otherwise)
☐ Make decisions for themselves
☐ Leave the situation if they want to
☐ Unknown

SECTION 3: TYPE OF ABUSE

3.1 Select All Types That Apply

☐ PHYSICAL ABUSE
Hitting, slapping, pushing, kicking, burning, restraining, rough handling

☐ EMOTIONAL/PSYCHOLOGICAL ABUSE
Verbal threats, intimidation, humiliation, isolation, controlling behavior

☐ SEXUAL ABUSE
Non-consensual sexual contact or exposure

☐ NEGLECT (by caregiver)
Failure to provide food, water, shelter, clothing, hygiene, medical care, safety

☐ SELF-NEGLECT
Elder is unable or unwilling to provide for their own basic needs

☐ FINANCIAL EXPLOITATION
Theft, fraud, misuse of money or property, undue influence, scams

☐ ABANDONMENT
Desertion of an elder by a caregiver

☐ CONFINEMENT
Unlawful restraint or imprisonment

☐ OTHER: _______________________________________________

SECTION 4: DETAILED DESCRIPTION OF ABUSE

4.1 What Happened?

Describe the abuse, neglect, or exploitation in detail:
(Include what you observed, what you were told, and what makes you believe abuse has occurred)

_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

4.2 When Did It Happen?

Date(s) of incident(s): _______________________________________________

Time of incident(s): _______________________________________________

Is the abuse:
☐ A single incident
☐ Ongoing/repeated
☐ Unknown

How long has the abuse been occurring?
_______________________________________________

4.3 Where Did It Happen?

Location of abuse:
_______________________________________________
_______________________________________________

4.4 How Did You Learn About This?

☐ I directly observed the abuse
☐ The elder told me
☐ Another person told me: _______________________________________________
☐ I observed signs/indicators of abuse
☐ Other: _______________________________________________

SECTION 5: SUSPECTED ABUSER INFORMATION

5.1 Suspected Abuser(s)

Name (if known): _______________________________________________

Relationship to Elder:
☐ Spouse/Partner
☐ Adult child
☐ Other family member: _______________________________________________
☐ Caregiver (paid)
☐ Caregiver (unpaid)
☐ Facility employee
☐ Friend/Acquaintance
☐ Stranger
☐ Unknown
☐ Other: _______________________________________________

Address (if known): _______________________________________________

Phone (if known): _______________________________________________

Description (if name unknown):
_______________________________________________
_______________________________________________

Does the suspected abuser live with the elder?
☐ Yes ☐ No ☐ Unknown

Does the suspected abuser have access to the elder's finances?
☐ Yes ☐ No ☐ Unknown

5.2 Multiple Abusers

☐ There is more than one suspected abuser

If yes, provide information for additional abusers:
_______________________________________________
_______________________________________________

SECTION 6: EVIDENCE AND INJURIES

6.1 Visible Injuries or Signs

Does the elder have visible injuries?
☐ Yes ☐ No ☐ Unknown

If yes, describe:
☐ Bruises - Location: _______________________________________________
☐ Cuts/Lacerations - Location: _______________________________________________
☐ Burns - Location: _______________________________________________
☐ Fractures - Location: _______________________________________________
☐ Pressure sores/Bedsores - Location: _______________________________________________
☐ Malnutrition/Dehydration
☐ Poor hygiene/Unkempt appearance
☐ Inappropriate clothing for weather
☐ Other: _______________________________________________

6.2 Behavioral Signs

Has the elder exhibited any of the following?
☐ Fear or anxiety around certain people
☐ Depression or withdrawal
☐ Sudden behavior changes
☐ Reluctance to talk openly
☐ Confusion about finances
☐ Unexplained changes in wills or financial documents
☐ Other: _______________________________________________

6.3 Documentation

Do you have any of the following evidence?
☐ Photographs
☐ Medical records
☐ Financial records
☐ Written statements
☐ Other documents

Describe evidence you have:
_______________________________________________
_______________________________________________

SECTION 7: FINANCIAL EXPLOITATION DETAILS (If Applicable)

7.1 Type of Financial Abuse

☐ Theft of cash or property
☐ Unauthorized use of credit/debit cards
☐ Unauthorized bank withdrawals
☐ Forged signatures
☐ Changes to will, POA, or deed
☐ Misuse of Power of Attorney
☐ Scams/Fraud schemes
☐ Undue influence on financial decisions
☐ Failure to use elder's funds for elder's care
☐ Other: _______________________________________________

7.2 Financial Details

Approximate amount involved: $_______________________________________________

Financial institutions involved:
_______________________________________________
_______________________________________________

Description of financial exploitation:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

SECTION 8: CURRENT DANGER AND URGENCY

8.1 Assess Current Danger

Is the elder in immediate danger?
☐ Yes - CALL 911 IMMEDIATELY
☐ No
☐ Unknown

Does the elder have any immediate needs?
☐ Medical attention
☐ Food/water
☐ Safe housing
☐ Protection from abuser
☐ Other: _______________________________________________

8.2 Weapons

Are there weapons in the home?
☐ Yes - Type: _______________________________________________
☐ No
☐ Unknown

8.3 Threats

Has the abuser made threats?
☐ Yes - Describe: _______________________________________________
☐ No
☐ Unknown

SECTION 9: OTHER INFORMATION

9.1 Witnesses

Are there other witnesses to the abuse?

9.2 Previous Reports

Have there been previous reports about this situation?
☐ No
☐ Yes - When: _______________________________________________
To whom: _______________________________________________
Outcome: _______________________________________________

9.3 Additional Information

Is there anything else that would help investigators?
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________

SECTION 10: EMERGENCY CONTACTS FOR ELDER

Family Member:
Name: _______________________________________________
Phone: _______________________________________________
Relationship: _______________________________________________

Doctor:
Name: _______________________________________________
Phone: _______________________________________________

Power of Attorney (if known):
Name: _______________________________________________
Phone: _______________________________________________

SECTION 11: HOW TO REPORT

11.1 Adult Protective Services (APS)

Your State's APS Hotline: _______________________________________________

National Eldercare Locator: 1-800-677-1116

Most states have 24-hour hotlines. Reports can often be made online as well.

11.2 Long-Term Care Ombudsman

For abuse in nursing homes or assisted living facilities:

Your State's Ombudsman: _______________________________________________

National Long-Term Care Ombudsman Resource Center: 202-332-2275

11.3 Law Enforcement

For criminal matters (assault, theft, fraud):

Local Police Non-Emergency: _______________________________________________

Emergency: 911

11.4 Other Resources

FBI Elder Fraud Hotline: 1-833-FRAUD-11 (1-833-372-8311)

State Attorney General: _______________________________________________

SECTION 12: REPORTER CERTIFICATION

I am making this report in good faith based on my observations, information, and belief. I understand that:

• Good faith reporters are protected from liability
• Making a false report may result in legal consequences
• My identity will be kept confidential to the extent permitted by law
• Investigators may contact me for additional information

Signature: _________________________________

Printed Name: _________________________________

Date: _________________________________

Time: _________________________________

SECTION 13: AGENCY USE ONLY

Report received by: _______________________________________________

Date received: _______________________________________________

Time received: _______________________________________________

Report number: _______________________________________________

Assigned investigator: _______________________________________________

Priority level: ☐ Emergency ☐ Urgent ☐ Non-urgent

This form is provided for informational purposes to help organize information for an elder abuse report. Actual reporting should be made to your state's Adult Protective Services, Long-Term Care Ombudsman (for facility residents), or law enforcement as appropriate. If someone is in immediate danger, call 911 first.