Indiana Division of Aging Adult Protective Services Online Reporting

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:

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:

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): *

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.