Adult Protective Services

Please fill out this form to report abuse, neglect, or exploitation. We need this information to contact you and the person who needs help. The information you provide will help us see if we can open a case. We will not sell your information. Only Adult Protective Services will use this data. APS cannot help without completed information. This data is part of record series 17485 and 17863 (Utah Code § 63A-19-402).

* The report I am submitting does not require an emergency response

Incident Information

Facility:

Address Line 1:

Line 2:

City:

Zip Code:

Public Intake

Please note fields marked * are required.

Client Information

*First Name:

Middle Name:

*Last Name:

* DOB:

OR Age:

Exact Age Unknown

SSN: ###-##-####

Language:

Speaks English

Veteran Status:

Race:

Ethnicity:

Gender:

Gender Other:

Sexual Orientation:

S.O. Other:

Living Arrangements:

Martial Status:

Home Phone :

Work Phone :

Cell/Other Phone:

Address:

City:

Zip Code:

Current Location: (if different from address)

Physical/Mental Impairments (if under 65):

Suspected Abuser #1

First Name:

*Last Name:

SSN:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Home Phone :

Work Phone :

Cell/Other Phone:

Address:

Lives with client

City:

State:

Zip Code:

DOB:

OR Age:

Ethnicity:

Race:

Eyes:

Hair:

Weight:

Height:

Suspected Abuser # 2

First Name:

*Last Name:

SSN:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Home Phone:

Work Phone :

Cell/Other Phone:

Address:

Lives with client

City:

State:

Zip Code:

DOB:

OR Age:

Ethnicity:

Race:

Eyes:

Hair:

Weight:

Height:

Suspected Abuser # 3

First Name:

*Last Name:

SSN:

Gender:

Collateral Type:

Resource Type:

Relation to Victim:

Home Phone:

Work Phone:

Cell/Other Phone:

Address:

Lives with client

City:

State:

Zip Code:

DOB:

OR Age:

Ethnicity:

Race:

Eyes:

Hair:

Weight:

Height:

Reporting Party

*First Name:

*Last Name:

Gender:

Ethnicity:

Race:

*Collateral Type:

Resource Type:

Relation to Victim:

*Email:

Primary Language:

*Work Place:

*Occupation:

Home Phone:

*Work Phone:

Other Phone:

*Address:

Lives with client

City:

State:

Zip Code:

Best time of day to reach you (25 chars max):

How did you hear about APS?:

Incident Information

Date of incident:

Time of incident:

*Address:

Use client address

Phone

City:

Zip Code:

Incident Occurred At:

Incident Other:

Select the institution reporting (if applicable):

Situation Reported

What happened today that led you to make this report? (Observations, beliefs, statements made by victim) (2000 characters max) *

Does the Suspected Abuser still have access to the victim?

Yes

If Yes, explain. Provide any known time frame (2 days, 1 week, ongoing etc.) (500 characters max)

If the Alleged Victim is under 65, please describe their cognitive and/or physical limitations. (Do they need a caregiver to meet their basic daily needs? Are they wheelchair dependent? What current third party assistance are you aware of for this person?) (500 characters max)

Is there a potential danger to the investigating worker, or other problem with access? (guns, animals, recent violence etc.)

Yes

If yes please specify: (500 characters max)

Please provide any other information that would help us investigate:

Other Persons Believed To Have Knowledge Of Abuse Family Member Or Other Person Responsible For Victim's Care. (If unknown, list contact person) Add Person

First Name:

Last Name:

Gender:

DOB

SSN

Invalid social security number. Example 1 2 3 - 4 5 - 6 7 8 9

Race

Collateral Type:

Resource Type:

Relation to Victim:

Email:

Primary Language:

Work Place:

Occupation:

Home Phone:

Work Phone:

Cell/Other Phone:

Address:

Lives with client

City:

State:

Zip Code:

* I understand that if I do not see a confirmation message my report has NOT been submitted and I must check for errors or incomplete entries on the form.

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