Protective Services Report
Reporter Information
In this section, you will fill out your contact information so that we can contact you if we need additional information. We must have at least your name and a phone number to ensure that we can properly address your concern in case additional information is needed.
Anonymous Report?
Mandated Reporter
required
Child Welfare Personnel
Clergy
Coroner
Day-care Personnel
Dentist
Financial Institution
Health Related Personnel
Hospital or Medical Personnel
Law Enforcement
Licensed Psychologist
Medical Examiner
N/A or Not Mandated
Occupational Therapist
Physical Therapist
Physician
Podiatrist
Professional Counselors/Therapist
Reproductive Health/Pregnancy Resource Personnel
RN/LPN
School Teacher/Administrator/Guidance Counselor
Social Worker
Unknown
Agency/Employer
Occupation
Your Title
Your First Name
Last Name
Middle Initial
Address Type
Home
School
Residential
Temporary
Vacation
Work
Unknown
Other
Mailing
Street Address of your Agency/Facility
Apartment/PO Box Number
City
select
select
State
select
select
Zip Code
select
select
Residency County
select
select
Contact Phone Number
Ext.
Phone Type
Home1
Cell
Work
Secondary Phone Number
Ext.
Phone Type
Home1
Home2
Fax
Message
Cell
Pager
Work
Unknown
Other
Modem
TTY/TDD
Voice
Voice/Fax
Voice/TTY/TDD
Email Address
Race Identity
American Indian/Alaska Native
Asian
Black/African American
Native Hawaiian/Pacific Islander
Other
Unknown
White
Did not Disclose
Additional Races
Ethnicity
Cuban
Did Not Disclose
Hispanic, Latino or Spanish Origin
Mexican
Mexican American
Not Hispanic, Latino or Spanish
Other
Puerto Rican
Unknown
Gender Identity
Male
Female
Transgender
Unknown
Not Answered
Date of Birth
Relationship to Involved Person
Advocate
Aunt
Bank
Brother
Church
Cousin
Co-Worker
Daughter
Dentist
Doctor
Domestic Partner
Elected Official
Friend
Grandchild
Grandparent
Health Practitioner
Husband
In-Law
Landlord
Lawyer
Mother
Neighbors
Non-Relative
Other
Other Professional
Other Relation
Parent
Self
Sibling
Sister
Social Worker
Son
Spouse
Step Brother
Step Parent
Step Sister
Teacher
Uncle
Unknown
Wife
Relationship to Incident
Alleged Perpetrator
Alleged Victim
Collateral Contact
Financial Institution
Household Member
Law Enforcement
Other
Other Professional
Primary Caretaker
Service Provider
Spouse
Staff
Unknown
Witness
Best time to contact you or an alternative contact name and phone number
Should we send the acknowledgement of receipt of this report to the above address?
Yes
Unknown
No
Incident Information
In this section, you will describe what caused you to fill out a report on the involved person. If anyone saw the incident happen, you will need to add their contact information to the Other Participant Section. Please answer as many of the following questions as you can.
What date did the incident occur?
What Time?
:
Where did the incident occur?
Alleged Victim Home
Community Care/Day Care Facility
Community Program
Correctional Institution
Home Based Care
Home of Other
Homeless Shelter
Hospital
Licensed Assisted Living
Non Relative Home
Nursing Facility
Other
Rehabilitation Facility
State Institution
Unknown
Unlicensed Assisted Living
Did the incident occur at an Agency or Facility
Yes
Unknown
No
Agency/Facility Name
Agency/Facility Phone Number
Incident Street
Incident Appartment Number
City
select
select
State
select
select
Zip Code
select
select
Incident County
required
select
select
Has law enforcement been involved?
Previously Notified
Notification - Not Necessary
Notification - Emergency
Notification - Non-Emergency
Please describe the incident in details and include the following information.
What has happened that led you to report today?
required
Why do you suspect abuse/neglect/exploitation?
How did you become aware of the suspected abuse/neglect/exploitation?
What are the circumstances surrounding the suspected abuse/neglect/exploitation?
Do you think there is risk to our Investigator?
Yes
No
Unknown
If Yes, please explain.
Alleged Victim/Involved Person Information
Add
Edit
Edit
Delete
Delete
Alleged Perpetrator Information
Add
Edit
Delete
Edit
Delete
Other Possible Connected Individual Information
Add
Edit
Delete
Edit
Delete
WebIntake Version: v8.4.2.0.40308
Your request is being processed. Please wait.