Reporting Concerns for Vulnerable Adult Victims

ATTENTION PROFESSIONALLY MANDATED REPORTERS

If your forms already include your name, agency, contact information and victim information you may click here to directly upload your documents.
IF NOT, please complete reporter and victim information below before uploading your documents.

REPORTER INFORMATION

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

Your Last Name:

Your First Name:

Your Middle Name:

Primary Contact Number (include phone type):

Additional Contact Numbers (include Phone Types):

Do you consent to be contacted if additional information is needed?

Reporters relationship to the victim:

Address (work address if reporting as a professional):

City:

Zip Code:

County:

State:

(If reporting as a professional)

Your Agency:

Your Job Title:

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?

VICTIM LOCATION INFORMATION

Home Address:

City:

Zip Code:

County:

State:

Home/Work/Cell Telephone Numbers of any person in the report (please specify whom the number belongs to):

What is the victim's current location?

Did the incident take place at a Facility? If so, enter the Facility Name and Address:

Other than the current location listed above, are there any other known addresses or means to locate any person in the report over the next 24 hours (schools, work locations, etc.)?

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.

If an injury is being reported, is abuse and/or neglect suspected as the cause of the injury?

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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