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 Add Edit Edit Delete Delete Alleged Perpetrator Information Add Edit Delete Edit Delete Other Possible Participant Information Add Edit Delete Edit Delete Attachments Add Add Delete Delete

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