Protective Services Report

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Special Designation AH SW Courtesy Visit AH SW Roll Out APS Home Safe DHS Care Court COVID 19 Center of Excellence DHS ERC GIR GIR/Forensic Home Safe Homeless ICS Chinatown SC ICS Case One Gen ICS Santa Clarita ICS SSG ICS Wise Mandated Reporter IHSS Mandated Reporter Bank Mandated Reporter Hospital IR-Downgraded Referral to DCBA Referral to DHS Referral to DMH/Genesis Referral to the FC Referral to PG Repatriate Risk of Homelessness RPP Subpoena Tracking of Veterans Standby SW Roll Out Standby SW Courtesy Visit Reporter Information Section Instructions Anonymous Report? Mandated Reporter Yes No Agency/Facility Name Title First Name required Last Name required Middle Initial Address Type Home School Temporary Vacation Work Unknown Other Mailing Street Address Apt./Suite City select select State select select Zip Code select select County select select Primary Phone Number required Ext. Phone Type Home1 Work Secondary Phone Number Ext. Phone Type Home1 Work Email Race/Ethnicity White - Not Hispanic Black - Not Hispanic Hispanic American Indian / Alaskan Native Armenian Asian Cambodian Chinese Filipino Guamanian Hawaiian Japanese Korean Laotian Multiple Ethnicities Samoan Vietnamese Other Asian/Other Pacific Islander Other Unknown Decline to State Gender Male Female Transgender Male to Female Transgender Female to Male Genderqueer/Gender Non-binary Another Gender Identity Decline to State Date of Birth Relationship to Alleged Victim Adult Day Care Provider Adult Protective Services Staff Advocate Assisted Living/Board & Care Providers Attorney Aunt Caregiver / Custodian Child Clergy Conservator Counselor Cousin Daughter Dentist District Attorney Domestic Partner/Significant Other Elected Official Family/Friends Financial Institution Formal/Paid Caregiver Friend Grandchild Grandparent Health Care Provider Health Practitioner Home Health Provider Hospital Discharge Planner/Social Worker Hospital Other Husband IHSS Provider IHSS Social Worker Informal/Unpaid Caregiver Law Enforcement Meal Provider Money Manager Neighbor Nurse Nursing Facility Staff Offspring Other Other Relative Paramedic/EMT Parent Physical Therapist Physician Power of Attorney/Durable Power of Attorney Private Agency Provider Probate Court Psychiatrist/Psychologist Public Agency Provider Regional Center Provider Self Senior Service Agency Provider Sibling Sister Social Services Agency Provider Social Worker/Case Manager Son Spouse Teacher Transportation Provider Uncle Unknown Relationship to Incident Alleged Perpetrator Alleged Victim Law Enforcement None Witness Unknown Local Ombudsman Calif. Dept. of Developmental Services Calif. Dept. of Mental Health Best Time to Contact Incident Information Section Instructions Date of Incident Time of Incident : Location of Incident required Own Home Home of Another Community Care Facility Hospital/Acute Care Hospital Nursing Facility/Swing Bed Financial Institution Unknown Other Did the Incident occur at an Agency or Facility? Yes Unknown No Agency/Facility Name Agency/Facility Phone Number Street Address Apartment Number City select select State select select Zip Code select select County select select Has Law Enforcement been involved? Previously Notified Notification - Not Necessary Notification - Emergency Notification - Non-Emergency Please provide a detail description of the Incident, including the following information: What happened that led you to report today? 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? Risk to an APS Investigator? Yes No Unknown If yes, please explain. Alleged Victim Information Add Edit Edit Delete Delete Alleged Perpetrator Information Add Edit Delete Edit Delete Other Participant Information Add Edit Delete Edit Delete

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