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. Per RI General Law 42-66-10, protective service records of OHA are deemed confidential. Therefore, OHA is unable to provide information back to reporters or other callers on the status and/or outcome of any cases reported to ERS.
Report Source
Behavioral Health Agency
Case Management Agency
EMS
Fire Department
Health Practitioner
Home Care Agency
Hospital
Law Enforcement
Other
Physician
Social Worker
Staff of Adult Day Care Services
Staff of Assisted Living
Visiting Nurse Agency
Agency/Facility Name
Your Title
Your First Name
required
Last Name
required
Street Address of your Agency/Facility
Apartment/PO Box Number
City
select
select
State
select
select
Zip Code
select
select
County
select
select
Contact Phone Number
required
Ext.
Phone Type
Work
Cell
Fax
Home1
Other
Pager
TTY/TDD
Secondary Phone Number
Ext.
Phone Type
Work
Cell
Fax
Home1
Other
Pager
TTY/TDD
Email Address
Primary Race
American Indian and Alaska Native
Asian
Black or African American
Native Hawaiian and Pacific Islander
Some Other Race
Unknown
White
Ethnicity
Non Hispanic or Latino
Hispanic or Latino
Other
Unknown
Gender
Male
Female
Transgender
Date of Birth
Age
Relationship to Client
Advocate
Attorney
Bank
Case Manager
Church
Dentist
Doctor
Elected Official
Health/Medical Professional
Legal Guardian
Other Professional
Social Worker
Best time to contact you or an alternative contact name and phone number should further information be needed
COVID-19 Screening
1. Is the allegation or report related to COVID-19?
2. Please describe why the allegation or report is related to COVID-19.
3. Is the alleged victim, or anyone in the home experiencing symptoms consistent with COVID-19 (fever, cough, shortness of breath, loss of appetite or diarrhea )?
Yes
No
Don't Know
Refused
4. When did your symptoms begin?
5. Have you, the alleged victim, or anyone in the home, had contact with someone who has had the flu, pneumonia, or confirmed COVID-19 in the last 14 days?
Yes
No
Don't Know
Refused
6. Has the alleged victim, or anyone in the home been asked to self quarantine or isolate? If yes, Date? If No, end.
Yes
No
Don't Know
Refused
7. Date asked to self quarantine or isolate.
8. Please describe why alleged victim (or anyone in the home) was asked to self quarantine or isolate.
9. Has alleged victim been tested for COVID-19? If yes, then following Questions, if no, end.
Yes
No
Don't Know
Refused
10. If known, what is the COVID-19 test result or confirmed disease status?
Positive - Confirmed to have COVID-19
Negative - Confirmed Not to have COVID-19
11. If tested for COVID-19, what date were the test results provided to you?
12. What is your current symptomatic disposition?
Currently symptomatic
No longer symptomatic
Confirmed Recovery
Deceased
13. Current symptomatic disposition date:
Incident Information
In this section, you will describe what caused you to fill out a report on the client. 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?
required
Client Home
Home of Caregiver or Family Member
Licensed Adult Day Services Center
Licensed Nursing Home
Other
Did the incident occur at an Agency or Facility
Yes
Unknown
No
Agency/Facility Name
Agency/Facility Phone Number
Incident Street
Incident Apartment 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
Notification - Reporter Will Notify
Please describe the incident in details and include the following information.
Do you suspect abuse, neglect and/or financial exploitation of client? If Yes, please explain.
Do you suspect self-neglect of client? If Yes, please explain.
Please provide information and specific details of the suspected abuse, neglect, exploitation or self-neglect.
What information do you have on the victim's functioning on a day-to-day basis?
What information do you have about the parent's discipline approaches?
What information do you have about how the caregiver functions on a day-to-day basis?
Do you think there is risk to our Investigator?
Yes
No
Unknown
If Yes, please explain.
Client/Involved Person Information
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Alleged Perpetrator Information
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Edit
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Other Possible Participant Information
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Edit
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Edit
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Attachments
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Delete
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