Exploitation Data Collection
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Long Term Care
This tool is intended to assist users in collecting
F-20441A (01/2009)
information to meet the requirements of
s. 46.90(8)c Wisconsin Statutes
ADULT-AT-RISK ABUSE, NEGLECT, AND / OR EXPLOITATION DATA COLLECTION
SECTION A: INITIAL INFORMATION
Referral Date (mm/dd/yyyy)
Reporting Year
Previous Report?
County/Tribe
Yes
No
Unknown
Text: Caller’s Initial Concerns (see Valid Values list)
Category: Primary Issue Identified During Response (select ONE reason from Valid Values list)
If “Other,” specify:
Details: Primary Issue Identified During Response
Other Issues Identified During Response
Date of Initial Contact (mm/dd/yyyy)
Yes
No
Unknown
Was incident life-threatening?
If life-threatening, has individual died?
Incident Occurred At or Near:
If yes, was death related to incident?
Place of Residence
Other (specify)
If yes, was death directly caused by incident?
Referral Source (see Valid Values list)
If “Other,” specify:
Call Received by (see Valid Values list)
If “Other,” specify:
Initial Response Agency Assigned (see Valid Values list)
If “Other,” specify:
SECTION B: INFORMATION ABOUT ADULT-AT-RISK
First Name (Elder Person)
MI
Last Name
Telephone Number
Address 1
Address 2
City
State
Zip Code
Sex
Ethnicity
Race (see Valid Values list)
Age in Years: ______
Male
Hispanic/Latino
Is this:
Female
Hmong
Actual age
Living Arrangement (see Valid Values list)
Unknown
Neither
Estimated age
County or State Programs/Services
Is There a Substitute
Type(s) of Substitute Decision-Maker (see Valid Values list):
Community Support Program
Decision-Maker?
Comprehensive Community Services
Yes
Family Care
No
Home & Community-Based Waivers
Unknown
Medicaid (Title 19, Card Services)
Other: _______________________
Unknown
None
Adult-at-Risk Characteristics (see Valid Values list)
If “Other,” specify:
Reference Code (Optional)
SECTION C: INFORMATION ABOUT ALLEGED ABUSERS
FIRST ALLEGED ABUSER
First Name (Alleged Abuser)
MI
Last Name
Telephone Number
Address 1
Address 2
City
State
Zip Code
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