Vulnerable Adult Protection Act:

Report on Abuse or Neglect

Name and address of vulnerable adult:

_____________________________________________________________________________

_____________________________________________________________________________

Date of Birth (of above named person): ___________________________________________

Directions to home (of above named person):

_____________________________________________________________________________

_____________________________________________________________________________

Name and address of caretaker:

_____________________________________________________________________________

_____________________________________________________________________________

Relationship of caretaker to the Vulnerable Adult: ___________________________________

Nature and extent of suspected abuse/neglect: _____________________________________

_____________________________________________________________________________

_____________________________________________________________________________

List evidence of previous abuse/neglect: __________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Name / Address / Home and Work Phone of person making this report:

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Any other useful information: ___________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

_____________________________________________________________________________

Printed Name and Signature of individual making this report:

_____________________________________________________________________________

Date of Report: ________________________________________________________________