* Indicates REQUIRED information. Enter N/A for unknown information.

REPORTER INFORMATION

This information is required for mandatory reporters. Refer to Chapters 415, Florida Statutes.

 

      

      




 




 


 

     

     

     


(If reporting as a professional)
 

     


VICTIM LOCATION INFORMATION


 


 

    

   *  

   *  





*  


 





VULNERABLE ADULT VICTIM'S INFORMATION

In this section please list all known victims

# First Name Last Name DOB/Age* Sex Race SSN Is This Person a Victim?*
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POSSIBLE RESPONSIBLE PERSON INFORMATION

In this section please list all individuals that are alleged to be responsible for the abuse, neglect, or exploitation. Also, list any known caregivers of the victim.

# First Name Last Name DOB/Age Sex Race SSN Relationship to Victim
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DESCRIPTION OF INCIDENT *

Please describe the following if known:WHAT happened, WHO'S involved, WHEN and WHERE did the incident occur, impacts/effects on the victims, a description of injuries and/or threat of harm, the frequency of occurrence, and the history of occurrences.



Describe how the victim meets the definition of a being a vulnerable adult *

For the victim, please identify all known physical, mental, or emotional disabilities or limitations that would impair their ability to care for or protect themselves. Also, identify if any person listed in the report has any hearing impairments, or limited English proficiencies. If hearing impairments are known, how does the individual communicate? Does the individual utilize any devices to assist with communication?



OTHER INDIVIDUALS

Please list other individuals who might be aware of the abuse, abandonment, neglect, or exploitation of the victim.

# First Name Last Name Relationship to Victim Address Home Phone Work Phone
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