Adult Protective Services

If you suspect harm is occurring right now, call 911. This form is for submitting non-emergency reports.

* The report I am submitting does not require an emergency response

Incident Information

Facility:

Address Line 1:

Line 2:

City:

Zip Code:

Public Intake

Please Contact your Administrator to update the APS Referrer List

Please note fields marked * are required.

Client Information

*First Name:

Middle Name:

*Last Name:

* DOB:

OR Age:

Exact Age Unknown

SSN: ###-##-####

Language:

Speaks English

Veteran Status:

Race:

Ethnicity:

Gender:

Gender Other:

Sexual Orientation:

S.O. Other:

Living Arrangements:

Martial Status:

Home Phone :

Work Phone :

Cell/Other Phone:

Address:

City:

Zip Code:

Current Location: (if different from address)

Physical/Mental Impairments (if under 65):

Suspected Abuser #1

First Name:

*Last Name:

SSN:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Home Phone :

Work Phone :

Cell/Other Phone:

Address:

Lives with client

City:

State:

Zip Code:

DOB:

OR Age:

Ethnicity:

Race:

Eyes:

Hair:

Weight:

Height:

Suspected Abuser # 2

First Name:

*Last Name:

SSN:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Home Phone:

Work Phone :

Cell/Other Phone:

Address:

Lives with client

City:

State:

Zip Code:

DOB:

OR Age:

Ethnicity:

Race:

Eyes:

Hair:

Weight:

Height:

Suspected Abuser # 3

First Name:

*Last Name:

SSN:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Home Phone:

Work Phone:

Cell/Other Phone:

Address:

Lives with client

City:

State:

Zip Code:

DOB:

OR Age:

Ethnicity:

Race:

Eyes:

Hair:

Weight:

Height:

Reporting Party

*First Name:

*Last Name:

Gender:

Ethnicity:

Race:

*Collateral Type:

Resource Type:

Relation to Victim:

*Email:

Primary Language:

*Work Place:

*Occupation:

Home Phone:

*Work Phone:

Other Phone:

*Address:

Lives with client

City:

State:

Zip Code:

Best time of day to reach you (25 chars max):

How did you hear about APS?:

Incident Information

Date of incident:

Time of incident:

*Address:

Use client address

Phone

City:

Zip Code:

Incident Occurred At:

Incident Other:

Select the institution reporting (if applicable):

Situation Reported

What happened today that led you to make this report? (Observations, beliefs, statements made by victim) (2000 characters max) *

Does the Suspected Abuser still have access to the victim?

Yes

If Yes, explain. Provide any known time frame (2 days, 1 week, ongoing etc.) (500 characters max)

If the Alleged Victim is under 65, please describe their cognitive and/or physical limitations. (Do they need a caregiver to meet their basic daily needs? Are they wheelchair dependent? What current third party assistance are you aware of for this person?) (500 characters max)

Is there a potential danger to the investigating worker, or other problem with access? (guns, animals, recent violence etc.)

Yes

If yes please specify: (500 characters max)

Please provide any other information that would help us investigate:

Other Persons Believed To Have Knowledge Of Abuse Family Member Or Other Person Responsible For Victim's Care. (If unknown, list contact person) Add Person

First Name:

Last Name:

Gender:

DOB

SSN

Invalid social security number. Example 1 2 3 - 4 5 - 6 7 8 9

Race

Collateral Type:

Resource Type:

Relation to Victim:

Email:

Primary Language:

Work Place:

Occupation:

Home Phone:

Work Phone:

Cell/Other Phone:

Address:

Lives with client

City:

State:

Zip Code:

* I understand that if I do not see a confirmation message my report has NOT been submitted and I must check for errors or incomplete entries on the form.

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