Note: Any fields with * are required

 VICTIM
 
   *
  *
  
    
  
  
    
  Address:
    
  Zip Code:  -   
    
      
        
      
  
  
  
  

 OFFENDER/PERPETRATOR
 
     *
       
        
   Community relationship such as doctor, pharmacist, bank teller, etc    Legal relationship Family relationship
    lbs   Height:  ft  in
        

  
  
             Zip Code:  - 

  
    
      
    

 OFFENDER/PERPETRATOR #2
 
     
       
        
   Community relationship such as doctor, pharmacist, bank teller, etc    Legal relationship Family relationship
    lbs   Height:  ft  in
        

  
  
             Zip Code:  - 

  
    
      
    

 OFFENDER/PERPETRATOR #3
 
     
       
        
   Community relationship such as doctor, pharmacist, bank teller, etc    Legal relationship Family relationship
    lbs   Height:  ft  in
        

  
  
             Zip Code:  - 

  
    
      
    

 REPORTING PARTY
  *   *
  *   *
   Legal relationship   * Family relationship Community relationship such as doctor, pharmacist, bank teller, etc
        

  *
  
  
  
  Zip Code:  - 

   
     
       
     
 
 INCIDENT INFORMATION
           :  
*Address:
  
  
  
  
  Incident Zip Code: 
 - 
 
       
 
          
 
  Select the institution reporting (if applicable):
    

 REPORTED TYPES OF MALTREATMENT (check all that apply)
Maltreatment Resulted In:


   
Self Neglect Allegations:


 

Maltreatment Perpetrated by Others:

 


*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?
  If Yes, explain. Provide any known time frame (2 days, 1 week, ongoing etc.) (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:
      (last 4 digits)
    Type of Account:
Type of Account
    Trust Account:
Trust Account
    Power of Attorney:
Power of Attorney
    Direct Deposit:
Direct Deposit
    Other Accounts:
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)
  
    
   Community relationship such as doctor, pharmacist, bank teller, etc Family relationship Legal relationship
  

  
  
             Zip Code:  - 

  
    
      
    

  
  


* Emergency responses must be submitted by phone
* On report submission you'll be directed to a confirmation page
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