DHS 1640 (Rev. 3/15)
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State of Hawaii Social Services Division
DEPARTMENT OF HUMAN SERVICES Adult Protective & Community Services Branch
CONFIDENTIAL
REPORT FORM FOR SUSPECTED ABUSE AND NEGLECT OF
VULNERABLE ADULTS
In accordance with HRS §346-224, to file a report of abuse, neglect, and/or exploitation of vulnerable adults, please:
1. Review available records and fill this form as completely as possible. Please type or print legibly. Use Y
for Yes,
N
for No, or as specified. If requested information is not known, use U for Unknown. If not applicable, use N/A for
Not Applicable.
2. Immediately call the Adult Protective Services (APS) Intake Reporting Line in your county to report your
findings. Refer to the last page of this form for contact information.
3. FAX, e-mail, or mail this form with comments to APS immediately after verbally reporting to the intake worker.
If you are a mandated reporter, submission of this form fulfills your statutory obligation under Hawaii Revised
Statutes (HRS) §346-224 requiring a written report as well as an oral report.
REPORTER INFORMATION
Check if you are a Mandated Reporter Check if anonymity is requested
Name / Agency / Title (as applicable):
Address: Phone Number:
Is this a direct number? Yes No
Relationship to alleged victim:
TYPE OF HARM (check all that apply)
Physical Abuse Sexual Abuse Self Neglect
Psychological Abuse Caregiver Neglect Financial Exploitation
Date of
Incident:________________
Location: Home
Care/Foster Home
Nursing Facility
Hospital
Other:______
_____________
VULNERABLE ADULT INFORMATION
Name (Last, First, M.I.)
Date of Birth: Gender:
Male Female
Home Address (Including apartment / unit number):
Phone Numbers (Home / Cellular / Other):
Living Arrangement (i.e., Lives alone, with family, spouse, caregiver, etc.):
Present Location (If different from above, i.e. care home, with other family, etc.):
Ethnicity:
Primary Language Spoken, if known:
Communicates verbally? Yes No Unknown Interpreter needed? Yes No Unknown
Disabilities seen (i.e., physical, medical, or behavioral conditions, vulnerability of the adult):
Mobility impairment
Medical condition
Hearing or vision impairment
Behavioral condition
Frail or appears ill
Other
(specify):__________________________
