Suspected Elder or Vulnerable Adult Abuse Report Form

Documents observed signs of abuse, reporter information, and Adult Protective Services contact details for suspected abuse of an older or dependent adult. Supports mandatory reporting compliance for social services staff and case managers.

Reporter Information

• Reporter Full Name
• Job Title / Role
• Organization / Agency
• Reporter Phone Number
• Reporter Email Address
• Date of This Report
• Reporter's Relationship to Victim
• If 'Other', describe relationship

Victim Information

• Victim Full Name
• Victim Age (years)
  Enter approximate age if exact age is unknown.
• Victim Gender Identity
• Victim's Current Address
• Victim Phone Number
• Victim's Living Situation
• Known Cognitive / Functional Limitations
  Select all that apply based on case records or direct observation.
• Victim's Primary Language
• Is an interpreter needed for APS contact?

Alleged Perpetrator Information

• Is the alleged perpetrator known?
• Alleged Perpetrator Full Name
• Alleged Perpetrator's Relationship to Victim
• Does the alleged perpetrator currently have access to the victim?
• Does the alleged perpetrator live with the victim?

Observed Indicators of Abuse or Neglect

• Type(s) of Suspected Abuse or Neglect
  Select all types suspected based on observation or disclosure.
• Date Abuse / Neglect Was First Observed or Reported
• Location Where Indicators Were Observed
• Physical Indicators Observed
  Select all directly observed physical signs.
• Behavioral / Emotional Indicators Observed
• Financial Exploitation Indicators
• Detailed Description of Observed Indicators
  Describe what you directly observed, heard, or were told. Include dates, times, and direct quotes where possible. Use objective, factual language.
• Is the victim in imminent danger?
  Imminent danger requires immediate APS and/or law enforcement notification.
• Has law enforcement been notified?
• Law Enforcement Agency and Report / Case Number
• Supporting Documentation (photos, records, notes)
  Attach photographs of injuries, relevant case notes, or financial records. Do not include documents containing SSN or full financial account numbers.

APS Notification and Actions Taken

• Has an APS report been made?
• APS Agency Name
• Date APS Was Contacted
• APS Worker / Contact Name
• APS Case / Referral Number
• If APS has not been notified, explain reason and planned timeline
• Protective Actions Taken
• Describe other protective actions taken
• Has your supervisor been notified of this report?
• Scheduled Follow-Up Date
  Date by which follow-up contact with APS or the victim is planned.

Certification and Submission

• Additional Notes or Context
  Include any other relevant information not captured above.
• I certify that the information provided in this report is true and accurate to the best of my knowledge, and that I am filing this report in good faith as required under my state's mandatory reporting statute.
• Reporter Signature
• Signature Date