Report Form For Suspected Abuse And Neglect Of Page 2
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4VULNERABLE ADULT INFORMATION (con’t.)
Vulnerable adult’s appearance and behavior:
Alert, oriented
Alert, but forgetful
Nervous, anxious
Incoherent, confused
Unkempt, poorly groomed
Other (specify):_________________________
Additional information (i.e. changes in behavior, changes in appearance, grooming, ability to care for self, etc.):
Other vulnerable adults at risk?
Yes
No If yes, please attach additional pages as necessary:
PRESENTING CONCERNS OF VULNERABLE ADULT
Intellectual disability
Physical disability/Assistive device
Developmental disability
Mental health concerns
used:_______________________________
Substance abuse
Other (specify):_____________
Other mental health impairment
Death
(specify):____________________________
INDICATORS OF HARM:
Decubitus ulcers (bedsores)
Substantial / multiple skin bruising
Malnutrition
Injury causing substantial bleeding
Burns
Fractures / Broken bones
Failure to provide adequate care
Extreme mental distress
Misuse of medications
Evidence of sexual abuse
Other (specify):__________________
Please describe in detail:
ALLEGED PERPETRATOR(S): List facility if applicable
Check if Self Neglect, go to page 3.
Name (Last, First, M.I.) and nicknames, alias:
Age:
Gender:
Male
Female
Home Address (including apartment / unit number):
Phone Numbers (Home / Cellular / Other):
Work Address:
Relationship to the Vulnerable Adult:
Caregiver
Child
Spouse
Parent
Sibling
Family member (specify):
Health Practitioner
Financial Advisor
Other (specify):__________
________________________
_________________________
Ethnicity:
Primary Language Spoken, if known:
Interpreter needed?
Yes
No
Unknown
Does the alleged perpetrator still have access to the vulnerable adult?
Other perpetrators?
Yes
No If yes, please attach additional pages as necessary:
DHS 1640 (Rev. 3/15)
Page 2 of 4
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