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Run: Suspected Elder or Vulnerable Adult Abuse Report Form

Report suspected elder or vulnerable adult abuse with a structured record of reporter details, observed indicators, APS notification, and immediate protectiv...

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Reporter Information

Reporter Full Name (required)

Job Title / Role (required)

Organization / Agency (required)

Reporter Phone Number (required)

Reporter Email Address (required)

Date of This Report (required)

Reporter's Relationship to Victim (required)

If 'Other', describe relationship

Victim Information

Victim Full Name (required)

Victim Age (years) (required)

Enter approximate age if exact age is unknown.

Victim Gender Identity

Victim's Current Address (required)

Victim Phone Number

Victim's Living Situation (required)

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? (required)

Alleged Perpetrator Information

Is the alleged perpetrator known? (required)

Alleged Perpetrator Full Name

Alleged Perpetrator's Relationship to Victim

Does the alleged perpetrator currently have access to the victim? (required)

Does the alleged perpetrator live with the victim?

Observed Indicators of Abuse or Neglect

Type(s) of Suspected Abuse or Neglect (required)

Select all types suspected based on observation or disclosure.

Date Abuse / Neglect Was First Observed or Reported (required)

Location Where Indicators Were Observed (required)

Physical Indicators Observed

Select all directly observed physical signs.

Behavioral / Emotional Indicators Observed

Financial Exploitation Indicators

Detailed Description of Observed Indicators (required)

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? (required)

Imminent danger requires immediate APS and/or law enforcement notification.

Has law enforcement been notified? (required)

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? (required)

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 (required)

Describe other protective actions taken

Has your supervisor been notified of this report? (required)

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. (required)

Yes No N/A

Reporter Signature (required)

Signature Date (required)

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