MA Adult Protective Services Report

Reporter Information If this report is an emergency or requires immediate attention, DO NOT file an online report. Additionally, if you do not have the full address where the elder resides you will not be able to file an online report. In such instances please make a verbal report to the Massachusetts Elder Abuse Hotline at 1-800-922-2275. When filing an online report it is important to provide as much detail as possible and complete all required fields. If you include your email address you will receive an email confirmation for your records after the report is submitted. Mandated Reporter required Not Mandated ASAP Employee Case Manager at Home Health Agency Case Manager at Homemaker Service Agency COA Outreach Worker Coroner Dentist Director of COA DPPC Emergency Medical Technician Executive Director of a Homemaker Service Agency Executive Director of a Licensed Home Health Agency Family Counselor Fire Fighter Home Health Aid Homemaker Licensed Psychologist Manager of an Assisted Living Residence Medical Intern Nurse Osteopath Physician Physician Assistant Police Officer Podiatrist Probation Officer Registered Occupational Therapist Registed Physical Therapist Social Worker Unknown Reporter Employer First Name required Last Name required Middle Initial Street required Street 2 City required select select State required select select Zip Code required select select Phone required Extension Phone Type required Home1 Home2 Fax Message Cell Pager Work Unknown Other Modem TTY/TDD Voice Voice/Fax Voice/TTY/TDD Email Address Relationship to Alleged Victim Advocate Bank Brother Care Manager Church Companion Daughter Dentist Doctor Domestic Partner Elected Official Ex-Spouse Friend Grandchild Guardian Ad Litem Health/Medical Professional Homemaker Husband In-Law Landlord Law Enforcement Lawyer Legal Guardian Neighbors Nephew Niece Non-Relative Other Family Other Professional Parent Personal Care Attendant Power of Attorney Self Sister Social Worker Son Spouse Wife Unknown Best time to contact Incident Information In this section, please describe what caused you to fill out a report on the involved person. If anyone saw the incident happen, you will need to add their contact information to the Other Participant Section. Please answer as many of the following questions as you can. Incident date required Incident Location required Alleged Victim Home Community Care/Day Care Facility Community Program Correctional Institution Home Based Care Home of Other Homeless Shelter Hospital Licensed Assisted Living Nursing Facility Other Rehabilitation Facility State Institution Unknown Unlicensed Assisted Living City Where Alleged Victim Resides required select select State Where Alleged Victim Resides select select Zip Code Where Alleged Victim Resides required select select Protective Service Agency required select select APS Report to be Screened By required select select Screening Code required Normal Review Priority Review Has law enforcement been involved? Previously Notified Notification - Not Necessary Notification - Emergency Notification - Non-Emergency Is this a Self-Neglect report? required No Yes Please describe the incident in details and include the following information. Describe the elder’s current physical, emotional, and mental status including medical issues, medications the elder takes, services the elder receives, any confusion or memory loss, and whether the elder has the ability to make his/her own decisions. Describe the type of housing the elder resides in (ex. private home, apartment, assisted living, etc.); who lives with the elder (provide names and contact information if possible); any concerns about the physical condition of the elder’s housing (be as specific as possible). required Explain why you are reporting today and if you suspect any of the following: physical abuse, emotional abuse, sexual abuse, caretaker neglect, financial exploitation, and/or self-neglect. Provide as much detail as possible including, names, dates, locations, and any injury or harm to the elder. If this is a financial exploitation case, please provide detailed information regarding the elder’s finances. required Explain the elder’s current level of risk. Is the abuse/ neglect a long term or ongoing problem? Can the elder call for help if necessary? required Does the alleged perpetrator still have access to the elder or the elder’s finances (financial exploitation)? required Has the elder been admitted to the hospital, if so how long will the elder remain? Any concerns around losing housing (eviction, foreclosure, etc.) If the elder is being evicted, when is the eviction date? required Provide the name and contact information of the elder's Primary Care Physician (PCP). required Provide the name, contact information, and relationship to the elder of individuals involved with the elder who might need to be contacted as part of a Protective Services investigation: (such as Spouse, Family Member, Nurse, Home Health Aide, Health Care Proxy, Power of Attorney, etc.). required Do you think there is a risk to a PS Investigator, such as weapons, drugs, or dangerous animals, should they visit the elder? required Yes No Unknown If Yes, please explain. Alleged Victim Information Add Edit Edit Delete Delete Alleged Perpetrator Information Add Edit Delete Edit Delete Other Participant Information Add Edit Delete Edit Delete Attachments Add Add Delete Delete

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