Protective Services Report
REQUIRED FIELD TO START INTAKE - - - Are you reporting an incident that happened to an adult or a child?
required
Child
Adult
Reporter Information
In this section, you will fill out your contact information so that we can contact you if we need additional information. We must have at least your name and a phone number to ensure that we can properly address your concern in case additional information is needed.
Report Source
required
Mandated Reporter
Yes
No
Agency/Employer Name
Your Title
Your First Name
required
Last Name
required
Middle Initial
Address Type
Business (B)
Homeless (H)
Mailing (M)
Other
Placement (P)
Residence (R)
School
Temporary
Unknown
Street Address of your Agency/Facility
Apartment/PO Box Number
City
select
select
State
required
select
select
Zip Code
select
select
County
select
select
Primary Phone Number
required
Ext.
Phone Type
Home1
Work
Cell
Fax
Other
Secondary Phone Number
Ext.
Phone Type
Home1
Work
Cell
Fax
Other
Email Address
required
Gender
Female
Male
Unknown
Relationship to Alleged Victim
required
Best time to contact you or an alternate contact name and phone number
required
Language Spoken
English
Arabic
Chinese
French
German
Hmong
Farsi
Italian
Japanese
Korean
Lao
Russian
Somali
Sign Language
Spanish
Swahili
Vietnamese
American Sign Language
Other
Interpreter/Translator Needed?
Are you at risk from the Alleged Perpetrator?
Yes
No
Unknown
Would you like written notification of the outcome of your Report?
Yes
No
Incident Information
In this section, you will describe what caused you to fill out a report on the alleged victim. 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.
On what date did the incident occur?
What Time?
:
Where did the incident occur?
required
Alleged Victim Home
Community Care/Day Care Facility
Community Program
Detention Center
Foster Home
Group Home/Residential Facility
Home Based Care
Home of Non Residential Parent
Home of Other
Home of Relative
Homeless Shelter
Hospital
Juvenile Correctional Facility
Licensed Assisted Living
Nursing Facility
Other/Unknown
Psychiatric Residential Treatment Facilities (PRTF)
School
State Institution
Unlicensed Assisted Living
Did the incident occur at an Agency or Facility?
Yes
No
Unknown
Agency/Facility Name
Agency/Facility Phone Number
Incident Street
Incident Apt/PO Box Number
City
select
select
State
select
select
Zip Code
select
select
County
select
select
Has law enforcement been involved?
Previously Notified
Notification - Not Necessary
Notification - Emergency
Notification - Non-Emergency
Sending Additional Documentation via
U.S. Mail
Fax
Separate Email
Please describe the incident in detail and include the following information.
What has happened that led you to report today?
required
Why do you suspect abuse/neglect/exploitation?
required
How did you become aware of the suspected abuse/neglect/exploitation?
What are the circumstances surrounding the suspected abuse/neglect/exploitation?
What information do you have on the victim's functioning on a day-to-day basis? (For child reports only)
What information do you have about the parent's discipline approaches? (For child reports only)
What information do you have about how the caregiver functions on a day-to-day basis? (For child reports only)
Do you think there is risk to our Investigator?
Yes
No
Unknown
If Yes, please explain.
Alleged Victim Information
required
Add
Edit
Edit
Delete
Delete
Alleged Perpetrator Information
required
Add
Edit
Delete
Edit
Delete
Other Possible Participant Information
Add
Edit
Delete
Edit
Delete
Attachments
Add
Add
Delete
Delete
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