Fillable Commonwealth of Massachusetts Elder Abuse Mandated Reporter Form

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Commonwealth of Massachusetts Elder Abuse Mandated Reporter Form

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The Commonwealth of Massachusetts Elder Abuse Mandated Reporter Form form is 3 pages long and contains:

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BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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EXECUTIVE OFFICE OF ELDER AFFAIRS
COMMONWEALTH OF MASSACHUSETTS
ELDER ABUSE MANDATED REPORTER FORM
This form should be returned within 48 hours of the oral report, to the following Designated
Protective Service Agency:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Reporter Information:
Name: _________________________ Occupation: _________________________
Agency: ________________________ Address: _________________________
Tel. #: _________________________ _________________________
__________________________________________________________________________________
Information about Elder Being Allegedly Abused/Neglected:
Name: _______________________________________________________________
Address: _______________________________________________________________
Permanent: _______________________________________________________________
Temporary: _______________________________________________________________
Tel. #: ___________________________
Approximate Age: ______ Sex: ______ Preferred Language: ______
Is the elder aware a report is being made? ______ Is English spoken? ______
__________________________________________________________________________________
Description of alleged abuse incidents and/or condition of neglect: Include name, dates, times,
and specific facts and any information regarding prior incidents of abuse/neglect.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
9/29/2017
Yes
Yes
Persons or Agencies Involved or Knowledgeable about Elder:
Name _______________________________ Age _____ Relationship _________________
Address ___________________________________________ Phone ______________________
Name _______________________________ Age _____ Relationship _________________
Address ___________________________________________ Phone ______________________
Name _______________________________ Age _____ Relationship _________________
Address ___________________________________________ Phone ______________________
Name _______________________________ Age _____ Relationship _________________
Address ___________________________________________ Phone ______________________
Name _______________________________ Age _____ Relationship _________________
Address ___________________________________________ Phone ______________________
__________________________________________________________________________________
Is medical treatment required immediately? Yes ____ No ____ Possibly ____
Describe treatment needed or already received: _________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Does the reporter believe the situation constitutes an emergency?
Yes ____ No ____ Possibly ____
Describe the risk of death or immediate and serious harm: ________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Additional information or comments:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Signature of Reporter Date
9/29/2017
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signature
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Dear Mandated Reporter:
The enclosed Elder Abuse Mandated Reporter Form should be used by mandated reporters to
report suspected elder abuse or neglect. Mandated reporters who suspect that an elderly person is
suffering from abuse or neglect should immediately make a verbal report to the Elder Abuse
Hotline 1-800-922-2275
. Then submit this form, within 48 hours, to the designated protective
service agency. The designated protective service agency serving your area is
___________________________________ and may be reached by telephoning ________________.
M.G.L. c19A (Ch. 604 of the Acts of 1982) requires that reporters file a written report to the
Executive Office or one of its designated agencies within forty-eight (48) hours of the oral report.
Please use the enclosed form to file your written report and complete this form to the best of your
ability.
This law states that:
No person required to report pursuant to the provision of subsection (a) shall be liable in
any civil or criminal action by reason of such report pursuant to the provision of
subsection (b) or (c) shall be liable in any civil or criminal action by reason of such report
if it was made in good faith. No employer or supervisor may discharge, demote, transfer,
reduce pay, benefits or work privileges, prepare a negative work performance evaluation,
or take any other action detrimental to an employee or supervisee who files a report in
accordance with the provision of this section by reason of such report.
The designated protective service agency will advise you of the response to your request within
forty-five (45) days of your oral response.
Thank you for your cooperation in reporting elder abuse. Please feel free to contact the
designated protective service agency in your area or the Executive Office of Elder Affairs at
(617) 727-7750 if you have any further questions.
Enc.
9/29/2017
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Commonwealth of Massachusetts Elder Abuse Mandated Reporter Form

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Completed 16 May 2020

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