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Abuse Reporting Form

You do not have to prove that a vulnerable adult has been abused, exploited or neglected in order to make a report; you only need to have reason to believe that abuse may have occurred. It is the responsibility of APS to investigate whether abuse, neglect or exploitation has occurred.  

Please provide as much information as you can.  (Required fields are marked with a red bullet.)  You  may remain anonymous, if you wish.  A hardcopy version of the form is also available for downloading here.

You may also contact Adult Protective Services directly if you suspect that a vulnerable adult has been harmed.  Call toll-free 1-800-564-1612 or (802) 871-3317. 

Note: The Division of Licensing and Protection cannot ensure the confidentiality or security of email transmissions.

Your Information
It is helpful to have your contact information, particularly if an investigator needs your assistance in the future. However, you may choose to remain anonymous, if you wish.
Please enter your first and last name
Please type your mailing address
Please include your area code
Ex. Relative, Neighbor, Caregiver
Alleged Victim Information
The alleged victim is the person who has been victimized or about whom you have concerns. Please provide as much information about the person as you can.
(Required)
Please enter the person's first and last name
Please type the person's street address
Please include the area code
(Required)
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Please describe where the alleged victim is currently living: licensed facility, relative's home, private residence, etc.
Please describe any disabilities and/or diagnoses of the alleged victim
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Please select all that apply and detail those team members in the following question
Please detail each team member's name, relationship to the alleged victim and contact information, if available
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(Required)



Ex. Nursing Home, Residential Care Home, Group Home



Includes residence in the psychiatric unit of a hospital






How long has the victim received care? Who is providing the care? What type of services are being delivered?
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Alleged Perpetrator Information
The alleged perpetrator is the person who may be responsible for abusing, neglecting or exploiting the alleged victim. Please provide as much information as you can.
Please enter the person's first and last name
Please enter the person's street address
Please include the area code
Ex. Relative, Caregiver, Fellow Resident



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Allegation Information
Please use this section to explain your concern for the alleged victim. Please provide as much information as you can.



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Has the alleged victim detailed when he/she chooses not to receive goods, services or personal care?



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Could the caregiver have reseasonably prevented the abuse, neglect or exploitation?



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Caregivers must seek medical treatment for patients or residents when care is necessary.



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Please include witness names, phone numbers and their relationship to the alleged victim.
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Is there anything else about the situation that you would like to share with APS?
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Thank you for alerting Adult Protective Services (APS) to a potentially harmful situation.  We appreciate your concern, and we will handle the allegation with seriousness and respect for all parties.  If you have questions, please direct your call to APS at the Division of Licensing and Protection: toll-free at 1-800-564-1612 or (802) 871-3317.

Note: The Division of Licensing and Protection cannot ensure the confidentiality or security of email transmissions.