H. OTHER PERSON BELIEVED TO HAVE KNOWLEDGE OF ABUSE.
(family, significant others, neighbors, medical providers and agencies involved, etc.)
B. SUSPECTED ABUSER
✔ Check if ■ Self-Neglect
3. Cross-Reported to: ■ CDHS, Licensing & Cert.; ■ CDSS-CCL; ■ CDA Ombudsman; ■ Bureau of Medi-Cal Fraud & Elder Abuse; ■ Mental Health; ■ Law Enforcement;
■ Professional Board; ■ Developmental Services; ■ APS; ■ Other (Specify) Date of Cross-Report:
4. APS/Ombudsman/Law Enforcement Case File Number:_____________________________________
ABUSE RESULTED IN (✔ CHECK ALL THAT APPLY) ■ NO PHYSICAL INJURY ■ MINOR MEDICAL CARE ■ HOSPITALIZATION ■ CARE PROVIDER REQUIRED
■ DEATH ■ MENTAL SUFFERING ■ OTHER (SPECIFY)
PLACE OF INCIDENT (✔ CHECK ONE)
■ OWN HOME
■ COMMUNITY CARE FACILITY
■ HOSPITAL/ACUTE CARE HOSPITAL
■ HOME OF ANOTHER
■ NURSING FACILITY/SWING BED
■ OTHER (Specify)
TO BE COMPLETED BY REPORTING PARTY. PLEASE PRINT OR TYPE. SEE GENERAL INSTRUCTIONS.
1. Report Received by:
L. RECEIVING AGENCY USE ONLY ■ Telephone Report ■ Written Report
K. WRITTEN REPORT Enter information about the agency receiving this report. Do not submit report to California Department of Social Services
Adult Programs Bureau.
■ Local APS ■ Local Law Enforcement ■ Local Ombudsman ■ Calif. Dept. of Mental Health ■ Calif. Dept. of Developmental Services
J. TELEPHONE REPORT MADE TO:
FAMILY MEMBER OR OTHER PERSON RESPONSIBLE FOR VICTIM’S CARE. (If unknown, list contact person).
E. REPORTED TYPES OF ABUSE (✔ CHECK ALL THAT APPLY).
D. INCIDENT INFORMATION - Address where incident occurred:
C. REPORTING PARTY: Check appropriate box if reporting party waives confidentiality to: ■ ✔ All ■ ✔ All but victim ■ ✔ All but perpetrator
A. VICTIM ■ Check box if victim consents to disclosure of information [Ombudsman use only - WIC 15636(a)]
2. Assigned ■
■ Ten-day Response
■ No Initial