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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