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 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 Waives Confidentiality Yes Yes, but reporter waived confidentiality No, Email report No, Faxed Report No, Anonymous report 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 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

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