Exploitation Data Collection Page 2
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2F-20441A Page 2
FIRST ALLEGED ABUSER, CONTINUED
Age in Years
Sex
Ethnicity
Race (see Valid Values list)
Is this:
Male
Hispanic/Latino
Actual age
Female
Hmong
Estimated age
Unknown
Neither
Relationship to Adult-at-Risk (see Valid Values list)
If “Other” relationship, specify:
Is Alleged Abuser a Caregiver?
Yes
No
Unknown
Does Alleged Abuser live
Alleged Abuser’s Legal Status (check all that apply):
with Adult-at-Risk?
Conservator
POA-Finances – Not Activated
Temporary Guardian
Yes
Guardian of the Estate
POA-Health Care – Activated
None
No
Guardian of the Person
POA-Health Care – Not Activated
Unknown
Unknown
POA-Finances – Activated
Representative Payee
Other (specify):
Alleged Abuser Characteristics (see Valid Values list)
If “Other,” specify:
SECOND ALLEGED ABUSER
First Name (Alleged Abuser)
MI
Last Name
Telephone Number
Address 1
Address 2
City
State
Zip Code
Age in Years
Sex
Ethnicity
Race (see Valid Values list)
Is this:
Male
Female
Hispanic/Latino
Actual age
Estimated age
Unknown
Hmong
Neither
Relationship to Adult-at-Risk (see Valid Values list)
If “Other” relationship, specify:
Is Alleged Abuser a Caregiver?
Yes
No
Unknown
Does Alleged Abuser live
Alleged Abuser’s Legal Status (check all that apply):
with Adult-at-Risk?
Conservator
POA-Finances – Not Activated
Temporary Guardian
Yes
Guardian of the Estate
POA-Health Care – Activated
None
No
Guardian of the Person
POA-Health Care – Not Activated
Unknown
Unknown
POA-Finances – Activated
Representative Payee
Other (specify):
Alleged Abuser Characteristics (see Valid Values list)
If “Other,” specify:
SECTION D: REPORT SUMMARY
Incident Result
Action(s) Taken (see Valid Values list)
Substantiated
Unsubstantiated
Unable to Substantiate
Services Planned for Adult-at-Risk (see Valid Values list)
If “Other,” specify:
Services Planned for Alleged Abuser/s (see Valid Values list)
If “Other,” specify:
Report Prepared by
Data Entry by (if different from Report Preparer)
Date Report Completed (mm/dd/yyyyy)
NOTE: This tool is for local use only. Do not send it to the Department of Health Services (DHS). Its purpose is to assist
users in gathering information that will be reported to DHS using the web-based Elder Abuse Reporting System. Although this tool
provides space to record personally identifiable information about elder abuse and alleged abusers, this identifying information is for
local/county use only and will not be entered into the Elder Abuse Reporting System.
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