Report Form For Suspected Abuse And Neglect Of Page 3
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4Do you think the vulnerable adult has decisional capacity?
Yes
No
Unknown
(HRS §346-222 defines capacity as: the ability to understand and appreciate the nature and consequences of making
decisions concerning one's person or to communicate these decisions.)
If no, why do you think the vulnerable adult lacks decisional capacity: _______________________________________
___________________________________________________________________________________________________
Is there any supporting documentation on decisional capacity?
Yes
No
Unknown
If yes, please attach.
SERVICES/TREATMENT HISTORY:
Check services or treatment the vulnerable adult or alleged perpetrator were offered prior to this report. Check all
that apply. List service provider and contact information in space below.
Medical / Health Services
Case management services
Domestic Violence/Abuse
Public Health Nursing
Behavioral Health Services
APS involvement (Hawaii or elsewhere)
Substance abuse counseling/treatment:
Financial Management / Services
Inpatient
Outpatient
Legal Services
Other (specify):____________________________
Service provider(s) and contact information:
SUPPORT SYSTEM:
Support system available and willing to assist the vulnerable adult. List name(s) and contact information in the
space below.
Spouse
Parent(s)
Child
Sibling(s)
Family Member(s)
Friend(s)
Church member(s)
Service providers
Community groups
Other (specify):_________
________________________
Name(s) and contact information:
NARRATIVE INFORMATION:
Describe the incident(s) and what action you believe needs to be taken. If known, include dates and location. List any
health and/or environmental hazards or concerns. Use additional pages as necessary.
___________________________________________________________________________________________________
Signature of Reporter
Date
THANK YOU FOR YOUR ASSISTANCE.
DHS 1640 (Rev. 3/15)
Page 3 of 4
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