Vermont Adult Protective Services Report

Reporter Information If this is a report from a staff member at a facility, please fill out using facility information. If the reporter is not part of the facility, the facility information should not be used. Anonymous Report? Mandated Reporter Mandated Voluntary Unknown Agency/Facility Name Your Title Your First Name required Last Name required Middle Initial Address Type Home School Temporary Work Other Mailing Facility Street Address of your Agency/Facility required Apartment/PO Box Number City required select select State required select select Zip Code required select select Residency County required select select Contact Phone Number required Ext. Phone Type required Home Cell Work Secondary Phone Number Ext. Phone Type Home Cell Work Email Address Gender Male Female Date of Birth Approximate Age Relationship to Alleged Victim required AAA Anonymous Attorney Bank Caregiver Civil Union Partner Dentist Developmental Disabilities Staff Doctor Domestic Partner Fellow Resident/Patient Fire/Rescue Friend Health/Medical Professional Home Health/VNA Home Provider Landlord Lawyer Legal Guardian Mental Health Staff Neighbor Non-Family Caregiver Non-Relative Nursing Home Staff Ombudsman Other Other Professional Police Probation/Parole Officer Relative Residential Care Home Staff Room Mate School Sibling Significant Other Social Worker Spouse Test-Additional Reporter1 Relationship to Incident required Alleged Perpetrator Alleged Victim Financial Institution Home Health VNA Household Member Law Enforcement Non-Relative Other Other Professional Legal Guardian Power of Attorney Primary Caretaker Relative Service Provider Spouse Staff Unknown Witness Additional Reporter Best time to contact you or an alternative contact name and phone number Are you at risk from the Alleged Perpetrator? Yes Unknown 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. What date did the incident occur? What Time? : Where did the incident occur (AV's Home, AP's Home, Reporter's Home, etc)? required Own Home Adult Day Care Provider Assisted Living Residence Correctional Institution Developmental Home Home of Other Homeless Shelter Hospital Non Relative Home Nursing Home Psychiatric Facility Relative's Home Residential Care Home Therapeutic Community Residence Other Unknown Home Health Agency Did the incident occur at an Agency or Facility Yes Unknown No Agency/Facility Name Agency/Facility Phone Number Incident Street Incident Apartment Number City select select State select select Zip Code select select Incident County required select select Has law enforcement been involved? Previously Notified Notification - Not Necessary Notification - Emergency Notification - Non-Emergency Incident Details Please describe the incident (specifically, the abuse, neglect, or exploitation) which led you to make this report: Please describe any conditions the alleged victim has that limit their ability to protect themselves: Please describe the alleged victim’s capacity to make decisions for themselves and their ability to do self-care activities. Examples include feeding, dressing, bathing, meal preparation, shopping, transportation, managing of finances, and management of medication: Is the incident ongoing and does the alleged perpetrator have ongoing contact with the alleged victim: If the report is opened for investigation, do you think there would be risk to our Investigator: Yes No Unknown If Yes, please explain. Alleged Victim Information Add Edit Edit Delete Delete If you selected the "Add" link button above and the page does not open, it is likely that your Pop Up Blockers are turned on. Please turn off the pop up blocker by accessing the Tools Menu -->Manage Pop Up Blocker. IF you are using Internet Explorer (IE) select the CTRL and ALT at the same time and then click on the "Add" link to open the page. Alleged Perpetrator Information Add Edit Delete Edit Delete If you selected the "Add" link button above and the page does not open, it is likely that your Pop Up Blockers are turned on. Please turn off the pop up blocker by accessing the Tools Menu -->Manage Pop Up Blocker. IF you are using Internet Explorer (IE) select the CTRL and ALT at the same time and then click on the "Add" link to open the page. Other Possible Participant Information Add Edit Delete Edit Delete If you selected the "Add" link button above and the page does not open, it is likely that your Pop Up Blockers are turned on. Please turn off the pop up blocker by accessing the Tools Menu -->Manage Pop Up Blocker. IF you are using Internet Explorer (IE) select the CTRL and ALT at the same time and then click on the "Add" link to open the page. Attachments Add Add Delete Delete If you selected the "Add" link button above and the page does not open, it is likely that your Pop Up Blockers are turned on. Please turn off the pop up blocker by accessing the Tools Menu -->Manage Pop Up Blocker. IF you are using Internet Explorer (IE) select the CTRL and ALT at the same time and then click on the "Add" link to open the page.

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