Adult Protective Services
Online Reporting
If this is an emergency, call 911 immediately.
*
Indicates a required field. Enter 'Unk' if unknown.
Reporting Person
First Name:
Last Name:
Professional:
*
Other info:
Phone #:
*
Alleged Endangered Person
First Name:
*
Last Name:
*
Street Address:
*
Street Address 2:
Zip:
City:
*
State:
County:
*
Phone #:
*
Date of Birth:
Approximate Age:
Gender:
*
Unit:
Self-Neglect?
Has Medicaid:
Veteran?
Alleged Perpetrator
First Name:
Last Name:
Phone #:
*
Describe how the alleged endangered person is incapacitated (Physical or mental impairment).
*
Describe how the alleged endangered person is being threatened with or being abused, neglected, and/or exploited.
Allegations (select all that apply):
*
Select all that apply
Neglect
Self-Neglect
BATTERY
EXPLOITATION
Risk Factors For APS Staff
Select all that apply
Select all that apply
Weapons in the house
Communicable illnesses
Police have been called to the house in the past 6 months
Drugs in the house
Dogs on property/in house
History of violence
Infestation (bed bugs/lice/rodents, etc)
Other
Explain Other:
Description
Describe any injuries, illness or other medical conditions resulting from abuse or neglect.
