VICTIM
 
  *First Name: Middle Name:  *Last Name:
  *Age (or approx. age): OR DOB:  SSN:  
  Language  Speaks English:  Race:
  Ethnicity:  Gender:  Gender Other:
  Sex at Birth:  Sexual Orientation:  S.O. Other:
  Living Arrangements:

  Home Phone Number:
  Work Phone Number: Ext: 
  Cell/Other Phone Number:

  Address:
  City:
  Zip Code:  - 
  Current Location:
  (if different from address)
  Vulnerabilities:
 SUSPECTED ABUSER #1
 
  First Name:  *Last Name:
  Age (or approx. age): OR  DOB:
  Eyes: Hair:  Weight: lbs Height: Ft In
  Gender:  Ethnicity: Race:
  Collateral Type: ?  Resource Type: ? Relation to Victim: ?
  Address Line 1:
  Address Line 2:
  City:   State:
  Zip Code:  - 
  Home Phone Number:
  Work Phone Number: Ext. 
  Cell/Other Phone Number:

 SUSPECTED ABUSER #2
 
  First Name:  *Last Name:
  Age (or approx. age): OR  DOB:
  Eyes: Hair:  Weight: lbs Height: Ft In
  Gender:  Ethnicity: Race:
  Collateral Type: ?  Resource Type: ? Relation to Victim: ?
  Address Line 1:
  Address Line 2:
  City:   State:
  Zip Code:  - 
  Home Phone Number:
  Work Phone Number: Ext. 
  Cell/Other Phone Number:

 SUSPECTED ABUSER #3
 
  First Name:  *Last Name:
  Age (or approx. age): OR  DOB:
  Eyes: Hair:  Weight: lbs Height: Ft In
  Gender:  Ethnicity: Race:
  Collateral Type: ?  Resource Type: ? Relation to Victim: ?
  Address Line 1:
  Address Line 2:
  City:   State:
  Zip Code:  - 
  Home Phone Number:
  Work Phone Number: Ext. 
  Cell/Other Phone Number:

 REPORTING PARTY

  *First Name:  *Last Name:
  Gender:  Ethnicity: Race:
  *Collateral Type: ?
 Resource Type: ?
Relation to Victim: ?
  *Email:  *Work Place: *Occupation:
  *Address Line 1:
  Address Line 2:
  City:   State:
  Zip Code:    - 
  *Work Phone Number: Ext.
  Other Phone Number:
  Home Phone Number:   Best time of day to reach you (25 chars max):

 INCIDENT INFORMATION

  Date and Time of this incident:         :  
  *Address: 
  Line 1:
  Line 2:
  City:
  Zip Code:  - 
  Incident Occurred At:       Incident Other: 
  Select the financial institution reporting (if applicable):
  Facility:  

 REPORTED TYPES OF ABUSE(Check All That Apply)

*Required
 Abuse Resulted In:



  If Other, please specify:  
  Self Neglect Allegations:  

 If Other, please specify:

 Abuse Perpetrated by Others:

Physical Abuse:
 If Other, please specify:

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

*Required

Does the Suspected Abuser still have access to the victim?
  If Yes, explain. Provide any known time frame (2 days, 1 week, ongoing etc.) (500 characters max)

If the Alleged Victim is under 60, 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.)
If yes please specify: (500 characters max)

 TARGETED ACCOUNT

  Targeted Account Information:
  Account Number (Last 4 Digits):    Type of Account:     Trust Account: 
  Power of Attorney:      Direct Deposit:      Other Accounts: 

OTHER PERSONS BELIEVED TO HAVE KNOWLEDGE OF ABUSE FAMILY MEMBER OR OTHER PERSON RESPONSIBLE FOR VICTIM'S CARE. (If unknown, list contact person)
 
  First Name: Last Name: Gender:
  Collateral Type: ? Resource Type: ? Relation to Victim: ?
  Email: Work Place: Occupation:
  Address Line 1:
  Address Line 2:
  City:
  State:          Zip Code:    - 

  Work Phone Number: ext: 
  Other Phone Number:
  Home Phone Number:

 WRITTEN REPORT (Enter information about the agencies receiving this report. Not required if only reporting to APS.)

Agency
 Contact First Name
Contact Last Name
Mailed
 Address
Date
Faxed
 Fax Number
Date
Agency
 Contact First Name
Contact Last Name
Mailed
 Address
Date
Faxed
 Fax Number
Date
Agency
 Contact First Name
Contact Last Name
Mailed
 Address
Date
Faxed
 Fax Number
Date


* ?
* ?
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