Adult Protective Services

Please review the following before submitting your online report:

Call 911 for crimes in progress or for medical emergencies.

This online report is only for concerns that do not involve immediate safety issues. If you cannot decide if your report is urgent or you believe APS needs to respond right away, please call our 24-hour Hotline at 916-874-9377.

If you submit an online report, there is no need to call our APS Hotline to make a verbal report. You will be contacted only if we need further information.

For mandated reporters who have already made a verbal report to the hotline, please do not complete this online report. Click here for the link to the SOC341 or SOC342 (financial institutions only).

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

Public Intake

Please note fields marked * are required.

Suspected Abuser #1

First Name:

*Last Name:

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:

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:

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):

Incident Information

Date of incident:

Time of incident:

*Address:

Use client address

City:

Zip Code:

Incident Occurred At:

Incident Other:

Select the institution reporting (if applicable):

Situation Report

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 60, 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)

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:

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:

Written Report (Enter information about the agencies receiving this report. Not required if only reporting to APS.) Add Agency

Agency

Contact First Name

Contact Last Name

Mailed

Address

Date

Faxed

Fax Number

Date

Agency

Contact First Name

Contact Last Name

Mailed

Address

Date

Faxed

Fax Number

Date

Agency

Contact First Name

Contact Last Name

Mailed

Address

Date

Faxed

Fax Number

Date

* 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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Alcohol and/or Drug Abuse	Hearing difficulties	Non-verbal Adult
Ambulatory difficulties	Intellectual disability	Other
Cognitive difficulties	Isolated	Self-care difficulties (Difficulties with ADL)
Death of Loved One Within A Year	Living Alone	Unknown
Debilitating or Serious Health Condition	Mental Illness	Unstable housing
Developmentally Disabled	No Identified Vulnerabilities	Vision difficulties
Difficulties with IADL	Non-English Speaker

Please review the following before submitting your online report:

Call 911 for crimes in progress or for medical emergencies.

This online report is only for concerns that do not involve immediate safety issues. If you cannot decide if your report is urgent or you believe APS needs to respond right away, please call our 24-hour Hotline at 916-874-9377.

If you submit an online report, there is no need to call our APS Hotline to make a verbal report. You will be contacted only if we need further information.

For mandated reporters who have already made a verbal report to the hotline, please do not complete this online report. Click here for the link to the SOC341 or SOC342 (financial institutions only).

Public Intake