STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
FOR USE BY FINANCIAL INSTITUTIONS
REPORT OF SUSPECTED DEPENDENT ADULT/ELDER
FINANCIAL ABUSE
DATE COMPLETED:
[CONFIDENTIAL - Not subject to public disclosure]
TO BE COMPLETED BY REPORTING PERSON. PLEASE PRINT OR TYPE.
A. VICTIM
GENDER
NAME (LAST NAME FIRST)
AGE
DATE OF BIRTH SSN
LANGUAGE (
CHECK ONE)
NON-VERBAL
ENGLISH
M
F
OTHER ( SPECIFY )
ADDRESS (IF FACILITY, INCLUDE NAME)
CITY
ZIP CODE
TELEPHONE
(
)
PRESENT LOCATION (IF DIFFERENT FROM ABOVE)
CITY
ZIP CODE
TELEPHONE
(
)
ELDERLY (65+)
DEVELOPMENTALLY DISABLED
MENTALLY ILL/DISABLED
PHYSICALLY DISABLED
UNKNOWN/OTHER
B. INCIDENT INFORMATION - WHERE INCIDENT OCCURRED
PLACE OF INCIDENT (
CHECK ONE)
FINANCIAL INSTITUTION
OWN HOME
CARE FACILITY
OTHER (Specify)
UNKNOWN
ADDRESS WHERE INCIDENT(S) OCCURRED
DATE/TIME OF INCIDENT(S)
C. REPORTER’S OBSERVATIONS
(ATTACH ADDITIONAL PAGES IF NECESSARY)
D. TARGETED ACCOUNT
ACCOUNT NUMBER: (LAST 4 DIGITS)
TYPE OF ACCOUNT:
DEPOSIT
CREDIT
OTHER
TRUST ACCOUNT:
YES
NO
OTHER ACCOUNTS:
YES
NO
POWER OF ATTORNEY:
YES
NO
DIRECT DEPOSIT:
YES
NO
E. SUSPECT INFORMATION
NAME OF SUSPECTED ABUSER(S)
ADDRESS
DATE OF BIRTH
AGE (ESTIMATE IF UNKNOWN)
RELATIONSHIP TO VICTIM
CARE CUSTODIAN
PARENT
SON/DAUGHTER
HEALTH PRACTITIONER
SPOUSE
UNKNOWN
OTHER___________________________________________
F. OTHER PERSON(S) BELIEVED TO HAVE KNOWLEDGE OF ABUSE - (family, significant others, neighbors, medical providers and
agencies involved, etc.)
NAME
ADDRESS
TELEPHONE NUMBER
RELATIONSHIP
G. TELEPHONE AND WRITTEN REPORTS
TELEPHONE REPORT MADE TO:
Local APS
Local Law Enforcement
Local Ombudsman
NAME OF OFFICIAL CONTACTED BY PHONE
TELEPHONE
DATE/TIME
(
)
REPORTED BY
TITLE
TELEPHONE
DATE/TIME
(
)
NAME OF FINANCIAL INSTITUTION
ADDRESS
Enter information about the agency receiving a copy of this report. Do not submit report to California Department of Social
WRITTEN REPORT SENT TO
Services Adult Programs Bureau.
NAME OF AGENCY
ADDRESS OR FAX #
Date Mailed
:
Date Faxed:
H. RECEIVING AGENCY USE ONLY
Telephone Report
Written Report
Date/Time:
1. Report Received by:
2. Assigned
Immediate Response
Ten-day Response
No Initial Face-To-Face Required
Not APS
Not Ombudsman
Approved by:
Assigned to (optional):
3. Cross-Reported to:
;
;
CDHS, Licensing & Cert.;
CDSS-CCL
CDA Ombudsman
Bureau of Medi-Cal Fraud & Elder Abuse
Mental Health;
Law Enforcement;
;
Professional Board;
Developmental Services;
APS;
Other (Specify)
Date of Cross-Report:
4. APS/Ombudsman/Law Enforcement Case File Number:_____________________________________
Use SOC 341 to report other types of abuse
SOC 342 (12/06)