Report of Abuse or Neglect
Subject of Report
Name
Address
Child
Elder
Intellectual developmental disability
Vulnerable population
Physical or mental impairment that prevents the person from providing for their own care or protection
Other (explain)
Abuse
Neglect
Exploitation
Injuries
Age
Reporting Child Abuse or Neglect
Reasonable cause to suspect that the individual has suffered or faces a threat of suffering physical or
mental wound, injury, disability, or condition of a nature that reasonably indicates abuse or neglect of the
child. Consult state law.
Nature, extent, and basis of the report and any information that might be helpful in establishing the basis of
the injury, abuse, or neglect or threat of injury, abuse, or neglect:
Reporting Abuse, Neglect, or Exploitation of Adult
Reasonable cause to believe that an adult has suffered abuse, neglect, or exploitation caused by self or
others. Consult state law.
Reporting Abuse, Neglect, and Other Major Unusual Incidents — Persons With an Intellectual
Developmental Disorder or Disability
Reasonable cause to believe a person with an intellectual developmental disability has suffered or faces a
substantial risk of suffering any wound, injury, disability, or condition of such a nature as to reasonably
indicate abuse or neglect of that person. Consult state law.
Report of (select at least one):
Known
Suspected
Type of information (select one):
This form is for educational and teaching purposes only. Students should use agency-provided forms,
follow agency policies and supervisory feedback, and comply with federal and state law and ethical codes.
Report of Abuse or Neglect
Name:
Reporter Name
_____________________________
Signature
Address:
Oral
Date
Time
Written
Date
Time
Custodian/Parent/Caretaker Information:
Report:
click to sign
signature
click to edit
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